The usefulness of the endoscopic surgical skill qualification system in laparoscopic right hemicolectomy: a single-center, retrospective analysis with propensity score matching

PURPOSE

Recently, a new certification system called the Endoscopic Surgical Skill Qualification System (ESSQS) has been launched in Japan to improve surgical safety. This study aimed to determine whether ESSQS-qualified surgeons affect the short- and long-term outcomes of laparoscopic right hemicolectomy.

METHODS

A total of 187 colon cancer patients who underwent laparoscopic right hemicolectomy at Kindai University Hospital between January 2016 and December 2020 were enrolled. These patients were divided into two groups based on surgeries performed by ESSQS-qualified surgeons (QS group) and non-ESSQS-qualified surgeons (NQS group). The short- and long-term outcomes were compared between the two groups before and after propensity score matching (PSM).

RESULTS

After PSM, 43 patients from each group were included in the matched cohort. In the short-term outcomes, the total operative time was significantly longer in the NQS group than in the QS group (229 vs. 174 min, p < 0.0001). However, there were no significant differences in the two groups regarding blood loss (0 vs. 0 ml, p = 0.7126), conversion (0.0% vs. 7.0%, p = 0.0779), Clavien-Dindo ≥ 2 complications (9.3% vs. 7.0%, p = 0.6933), mortality (2.3% vs. 0.0%, p = 0.3145), and postoperative hospital stay (9 vs. 9 days, p = 0.5357). In the long-term outcomes, there were no significant differences between the two groups in the 3-year overall survival (86.6% vs. 83.0%, p = 0.8361) and recurrence-free survival (61.7% vs. 72.0%, p = 0.3394).

CONCLUSION

Laparoscopic right hemicolectomy performed by ESSQS-qualified surgeons contributed to shorter operative time. Under the supervision of ESSQS-qualified surgeons, almost equivalent safety and oncological outcomes are expected even in surgeries performed by non-ESSQS-qualified surgeons.

Effectiveness of negative pressure wound therapy with instillation and dwelling after stoma closure: a retrospective and propensity score matching analysis

The use of temporary diverting stoma has become more common in low colorectal anastomosis to reduce anastomotic complications. Surgical site infection (SSI) at the stoma closure site has been one of the most frequent postoperative complications. The aim of this study was to compare the short-term outcomes between conventional primary suture closure and negative pressure wound therapy with instillation and dwelling (NPWTi-d) therapy following purse-string suturing, using propensity score matching analysis. We retrospectively evaluated the medical records of 107 patients who underwent stoma closure between January 2016 and October 2020. The primary outcome was the proportion of SSI. The secondary outcome was the day of postoperative length of stay. Propensity score matching with one-to-one match was performed for reducing treatment selection bias. Of a total of 107 patients, 67 patients had been treated with conventional primary closure and 40 with NPWTi-d therapy. The propensity score matching derived 37 pairs. The respective SSI proportions were 0% and 16.2% in the groups with NPWTi-d and primary closure (P = 0.025). The respective median days of postoperative hospital stay were 9.0 and 10.0 in the groups with NPWTi-d and primary closure (P = 0.453). NPWTi-d therapy with purse-string suturing was effective in reducing SSI after stoma closure.

Laparoscopic complete mesocolic excision with central vascular ligation for splenic flexure colon cancer: short- and long-term outcomes

Background

Complete mesocolic excision (CME) with central vascular ligation (CVL) for colon cancer is an essential procedure for improved oncologic outcomes after surgery. Laparoscopic surgery for splenic flexure colon cancer was recently adopted due to a greater understanding of surgical anatomy and improvements in surgical techniques and innovative surgical devices.

Methods

We retrospectively analyzed the data of patients with splenic flexure colon cancer who underwent laparoscopic CME with CVL at our institution between January 2005 and December 2017.

Results

Forty-five patients (4.8%) were enrolled in this study. Laparoscopic CME with CVL was successfully performed in all patients. The median operative time was 178 min, and the median estimated blood loss was 20 g. Perioperative complications developed in 6 patients (13.3%). The median postoperative hospital stay was 9 days. According to the pathological report, the median number of harvested lymph nodes was 15, and lymph node metastasis developed in 14 patients (31.1%). No metastasis was observed at the root of the middle colic artery or the inferior mesenteric artery. The median follow-up period was 49 months. The cumulative 5-year overall survival and disease-free survival rates were 85.9% and 84.7%, respectively. The cancer-specific survival rate in stage I-III patients was 92.7%. Recurrence was observed in 5 patients (11.1%), including three patients with peritoneal dissemination and two patients with distant metastasis.

Conclusions

Laparoscopic CME with CVL for splenic flexure colon cancer appears to be oncologically safe and feasible based on the short- and long-term outcomes in our study. However, it is careful to introduce this procedure to necessitate the anatomical understandings and surgeon’s skill. The appropriate indications must be established with more case registries because our experience is limited.

The technique for less infectious and earlier healing of stoma closure wound: negative pressure wound therapy with instillation and dwelling followed by primary closure

Background

Temporary stomas have been widely used to avoid the risk of complications such as anastomotic leakage after colorectal resection. Stoma closure is relatively easy; however, postoperative surgical site infection (SSI) may be a problem. Various methods have been used to reduce the incidence of SSI. We aimed to evaluate a new technique for stoma wound closure.

Methods

We enrolled patients who underwent stoma closure at our hospital between September 2019 and May 2020. We selected patients who lived far from our hospital and had difficulty visiting the hospital regularly and who agreed to undergo this surgical technique. We used negative pressure wound therapy with instillation and dwelling (NPWTi-d) and delayed primary closure for these patients.

Results

Four patients underwent NPWTi-d and delayed primary closure without the occurrence of SSI. The median postoperative hospital stay was 9 days (range: 7–14 days), and the median number of days to confirmation of epithelialization was 11.5 days (range: 10–16 days).

Conclusion

The combined use of NPWTi-d and delayed primary closure for the stoma wound was very effective. This method may be a valuable new technique for wound management after stoma closure.

Visualization of lymphatic flow in laparoscopic colon cancer surgery using indocyanine green fluorescence imaging

Intraoperative visualization of lymphatic flow could guide surgeons performing laparoscopic colon cancer surgery on the extent of intestinal resection required. The purpose of this study was to investigate indocyanine green fluorescence imaging for intraoperative detection of lymphatic flow and nodes in such patients. All patients undergoing elective laparoscopic surgery for colorectal cancer from October 2016 to July 2017 were included in this study. Indocyanine green was injected submucosally around the tumors via a colonoscope and lymphatic flow assessed with a laparoscopic near-infrared camera system intraoperatively. Lymphatic flow was visualized perioperatively in 43 of 57 patients (75.4%). The rate of visualized lymphatic flow was significantly higher in patients with a lower clinical stage than in those with a higher clinical stage (p = 0.0103). Among the 14 patients in whom lymphatic flow was not visualized, 10 (71.4%) had cStage III or IV cancer. Our results indicate the potential role of intraoperative navigation in colon cancer surgery in early-stage colon cancers. This method allows the surgeon to clearly identify lymphatic flow during surgery and allows the determination and individualization of the lymph node dissection range.

[A Case of Cecal Cancer Associated with Dermatomyositis]

We report a relatively rare case of cecal cancer with dermatomyositis. An 81-year-old man was diagnosed with dermatomyositis associated with the symptoms of eruption, limb muscle weakness, and difficulty swallowing. Colonoscopy revealed a type 2 tumor in the cecum. The patient underwent laparoscopic ileocecal resection. Although it was impossible for the patient to stand before the surgery, he could stand 10 days after the surgery and walk without assistance 14 days after the surgery. In addition, the eruption disappeared, and the preoperatively high creatine kinase(CK)value normalized. Dermatomyositis with malignant tumor has been reported to be associated with poor prognosis. Symptoms related to dermatomyositis may be improved by the resection of the associated tumor. Therefore, it is important to treat the malignant tumor when the patient's condition permits.

[Prognostic Implications of Programmed Cell Death Ligand-1(PD-L1)Expression on Tumor-Infiltrating Immune Cells and CD8+T Cells for Stage III Colorectal Cancer]

The purpose of this study was to evaluate the prognostic significance of programmed cell death-ligand 1(PD-L1)expression and CD8+T cells in the immune microenvironment. From January 2011 to December 2011, we retrospectively examined 31patients with Stage III colorectal cancer. PD-L1expression and CD8+T cell counts were evaluated by immunohistochemical study using whole-tumor slides. PD-L1expression in cancer cells(PDCC)and in tumor-infiltrating stromal cells(PDSC)was divided into high(H)and low(L)groups. CD8+T cells were counted in the core of the tumor(CDCT)and in the invasive margin of the tumor area(CDIM), and divided into high(H)and low(L)groups. Based on a median follow-up time of 69.3 months, the 5-year overall survival and disease-free survival of all patients were 74.2% and 64.5%, respectively. The overall survival was significantly longer for patients in the CDIM-H group(82.6%)than those in the CDIM-L group(50.0%; p= 0.034). Patients in the PDSC-H group also tended to have superior overall survival than those in the PDSC-L group(84.2% and 58.3%, respectively, p=0.094). In conclusion, both CD8+T cells and tumor-infiltrating immune cells with PD-L1may indicate antitumoral function in patients with Stage III colorectal cancer.

[A Case of Local Resection for Rectal GIST Following Neoadjuvant Imatinib Mesylate Treatment]

A 67-year-old woman presented with bloody stools and constipation. A rectal digital examination revealed a smooth and elastic hard tumor in the posterior wall of the rectum. We diagnosed the tumor as rectal GIST measuring 5 cm in diameter. Because the patient desired anal preservation, neoadjuvant imatinib mesylate(IM)(400mg/day)treatment was administered. Although the diameter of the tumor reduced to 2 cm in the third week of administration, the patient experienced erythema-type drug eruption(Grade 3). We discontinued the IM treatment and initiated steroid therapy. After the eruption had disappeared, IM treatment was resumed, initially with half doses. Local transanal resection was performed 36days after the neoadjuvant IM treatment. Currently, the indication and the administration period of IM for preoperative treatment is not clear. It may be necessary to accumulate cases to evaluate neoadjuvant IM therapy.

Clinicopathological and genetic differences between low-grade and high-grade colorectal mucinous adenocarcinomas

BACKGROUND

Although colorectal mucinous adenocarcinomas (MCs) are conventionally regarded as exhibiting high-grade differentiation, they can be divided by differentiation into 2 groups according to the glandular appearance: low-grade mucinous adenocarcinoma (low-MC) and high-grade mucinous adenocarcinoma (high-MC).

METHODS

Patients with colorectal cancer (CRC) who underwent surgical resection between 2000 and 2012 were enrolled in this study. Among the cases with MC, the clinicopathological and genetic differences between low-MC and high-MC were investigated with next-generation sequencing.

RESULTS

A total of 1373 patients with CRC were analyzed. Forty patients (2.9%) had MC, and 13 patients had high-MC. Patients with MC had significantly shorter disease-free survival (DFS) and overall survival (OS) periods than those with nonmucinous carcinoma. When low-MC patients and high-MC patients were compared, those with high-MC had significantly shorter DFS and OS periods than those with low-MC. Multivariate analyses revealed that high-MC was significantly associated with both shorter DFS and shorter OS, but low-MC was not. A genome analysis revealed that low-MC had a considerably larger number of mutations than high-MC, and Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations and adenomatous polyposis coli mutations were particularly frequently found in low-MC. In contrast, SMAD family member 4 (SMAD4) mutations were frequently found in high-MC.

CONCLUSIONS

High-MC is an independent prognostic factor in CRC (but low-MC is not), and it is genetically different from other CRCs, including low-MC. Both the clinicopathological differences and the genetic differences suggest that low-MC and high-MC should be distinguished in clinical settings.

Prognostic factors for patients with advanced colorectal cancer and symptomatic brain metastases

BACKGROUND

Increased rates of long-term survival after CRC diagnosis are accompanied by increases in the incidence of BMs. Here, we retrospectively evaluated the outcomes of patients with BMs from CRC.

MATERIALS AND METHODS

We reviewed the records of 1364 patients with CRC treated between January 1999 and December 2010 at Kinki University Hospital in Japan. Twenty-five of these patients developed BMs. Log-rank tests and Cox regression analyses were used to assess potential prognostic factors for survival.

RESULTS

Among the patients with BMs, BMs developed a median of 25.3 (range, 11.4-111) months after primary CRC surgery. There was a median of 2 BMs per patient. Eleven patients had solitary BMs. Concomitant extracerebral metastases, particularly lung metastases, were found in 23 patients. Twenty-three patients were receiving systemic chemotherapy at the time of diagnosis with BMs. After the development of BMs, the median survival time (MST) was 2.8 months. The MST was 4.8 months among patients who underwent neurosurgical resection (n = 6) or stereotactic surgery (n = 9, including combined therapy in 2 patients) and 1.5 months among patients who underwent whole-brain radiotherapy only or best supportive care (n = 12). In multivariate analysis, single BMs and additional systemic chemotherapy after BMs diagnosis were significantly associated with overall survival (P = .022 and .023, respectively).

CONCLUSION

Our results suggest that advancements in continuing systemic chemotherapy prolong survival among patients with BMs from CRC. Clinicians should be especially aware of BMs in patients with lung metastases.

Distal dissection in total mesorectal excision, and preoperative chemoradiotherapy and lateral lymph node dissection for rectal cancer

The local recurrence rate after total mesorectal excision (TME) appears to be markedly lower than that after conventional operations. We reviewed all relevant articles identified from the MEDLINE databases and clarified the rationale for TME. It is clear that distal intramural spread is rare. Even when present, such spread is not likely to extend beyond 2 cm. Data with attention to mesorectal cancer deposits suggest that mesorectal clearance of at least 4-5 cm distal to the tumor should be sufficient. TME should be performed for most tumors of the mid- and lower rectum. This does not mean that the gut tube needs to be divided at the same level in every case. Dissection of the distal mesorectum off the gut tube can be performed, so the distal line of division of the bowel wall can be made at a minimum of 2 cm below the tumor if such a maneuver would ensure that the sphincters are preserved. In cases with cancer in the upper third of the rectum, the mesorectum and gut tube can safely be divided 5 cm below the tumor without jeopardizing the recurrence rates. Our findings indicate that TME is an essential treatment approach for rectal cancer, and lateral lymph node dissection and preoperative chemoradiotherapy are additional therapies that should be considered for advanced rectal cancer.

Analyses of shape of eyes and structure of optic nerves in eyes with tilted disc syndrome by swept-source optical coherence tomography and three-dimensional magnetic resonance imaging

PURPOSE

To evaluate the deeper structures of the optic nerve and to analyze the shape of eyes with tilted disc syndrome (TDS) by swept-source optical coherence tomography (OCT) and three-dimensional magnetic resonance imaging (3D MRI).

METHODS

The medical records of 54 eyes of 36 patients with TDS were reviewed. The patients with TDS and high myopia were analyzed separately from those without high myopia. All the eyes were examined with a swept-source OCT, and 22 of the eyes were examined by 3D MRI.

RESULTS

A total of 38 eyes of 29 patients were highly myopic and 16 eyes of 15 patients were not highly myopic. The representative OCT findings of the optic disc were: a sloping of the lamina cribrosa posteriorly from the upper part to the lower part, a protrusion of the upper edge of Bruch's membrane, and choroid. The distance and the depth of the most protruded point from the fovea were significantly greater in the eyes with non-highly myopic TDS than those with highly myopic TDS. In the 3D MRI, the lower part of the posterior segment was protruded outward, and the optic nerves attached at the upper nasal edge of the protrusion.

CONCLUSIONS

The abnormalities detected by swept-source OCT and 3D MRI analyses indicate the possibility that the essential pathology of TDS is a deformity of the inferior globe below the optic nerve, and the positional relation between the fovea and the inferior protrusion determines the degree of myopia.

Characteristics of intrachoroidal cavitation located temporal to optic disc in highly myopic eyes

PURPOSE

To investigate the anatomic characteristics of eyes with pathological myopia and peripapillary intrachoroidal cavitation (ICC) located temporal to the optic disc.

METHODS

A total of 125 with pathologic myopia were scanned with swept-source optical coherence tomography (OCT). Temporal ICC was defined as ICC located temporal to the optic disc seen in horizontal OCT section through the optic disc center. Definition of pathologic myopia was refractive error >8.00 diopters (D) or an axial length >26.5 mm.

RESULTS

In all, 17 eyes of 16 patients had temporal ICC. All of the eyes had temporal or temporally wider annular conus. The ICC was observed temporal to the optic disc in 15 of 17 eyes, and 2 of the remaining eyes also had inferior ICC. Even in the two eyes with both temporal and inferior ICC, the temporal ICC was much wider than the inferior ICC. Inner retinal defect at the border of conus and temporal ICC was detected in two eyes. The temporal ICC was extensive in the posterior fundus with the average width of 1467.8 ± 1328.1 μm (range; 442-6200 μm) in a horizontal section. In two eyes, the temporal ICC extended beyond the central fovea.

CONCLUSIONS

Peripapillary ICC can develop temporal to the optic disc without involving the area inferior to optic disc in highly myopic eyes. Temporal ICC appeared much wider than inferior ICC, which is usually restricted to the area around the optic disc. The possible reasons why ICC develops in temporal to the optic disc are presented.

[Preliminary study of Peptide vaccine with UFT/LV as adjuvant setting for stage III colorectal cancer]

cDNA microarray technology has been used to identify HLA-A24-restricted epitope peptides as potential targets for cancer vaccination in metastatic colorectal cancer patients. We conducted a clinical trial of two novel cancer-specific peptides( RNF43, TOMM34) with UFT/LV for the treatment of recurrent colorectal cancer. Among 23 patients, 21 patients had completed the protocol. All patients were well tolerated with no severe toxicities. The median survival time was 24.4 months. Furthermore, we investigated the relationship between CTL response to both antigens and overall survival. The best long-term survival was observed in the group with CTL responses against both antigens, followed by the group showing CTL responses against only RNF43 or TOMM34. The patients with no response had the lowest survival. Based on the results, we started a randomized trial of the current protocol, as adjuvant immunochemotherapy in following curative resection of Stage III colorectal cancer patients.

Phase I clinical trial of a novel peptide vaccine in combination with UFT/LV for metastatic colorectal cancer

To test the safety and immune responses of a novel peptide vaccine derived from RNF43 (ring finger protein 43) and TOMM34 (34-kDa translocase of the outer mitochondrial membrane) administered in combination with chemotherapy in patients with metastatic colorectal cancer, a phase I clinical trial with 21 HLA-A2402-positive metastatic colorectal cancer patients was conducted. Patients received a weekly peptide vaccine (1 mg of each peptide in incomplete Freund's adjuvant) in combination with oral UFT (300 mg/m(2)/day) and UZEL (75 mg/day) for 4 weeks, followed by 1 week of rest. The protocol consisted of at least two cycles of this regimen. After the 2nd cycle, vaccinations were given biweekly or monthly, depending on the condition of the patient. Clinical responses were judged 10 weeks after the 2nd cycle by performing computed tomography (CT) scans and assessing the cytotoxic T lymphocyte (CTL) responses against RNF43 and TOMM34 in peripheral lymphocytes. The vaccinations were well tolerated without any serious adverse events. CTL responses were induced against both antigens in 8 patients and against one antigen in 12 patients, while 1 patient had no CTL response. The rate of stable disease was 83%. The group with CTL responses against both antigens had the most long-term survivors, followed by the group showing CTL responses against one antigen (p=0.0079). The patients with no CTL responses had the lowest survival. The safety and immunological responsiveness of the present combination therapy suggests that it is clinically beneficial for metastatic colorectal cancer. Further clinical trials are warranted.

[A case of complete response after treatment with UFT and leucovorin for synchronous multiple liver metastases of rectal cancer]

The patient was a 55-year-old female who had multiple liver metastases of rectal cancer. This patient underwent hepatic arterial infusion chemotherapy after low anterior resection for rectal cancer. Hepatic arterial infusion was discontinued due to severe diarrhea, and the administration of UFT (300 mg/day) and LV(75 mg/day) was then begun. The carcinoembryonic antigen (CEA) level was normalized immediately after the start of this administration. One year later, liver metastases disappeared on computed tomography (CT) and a complete response (CR) was achieved. No adverse events were noted, and CR was maintained for 2 years. This therapy can serve as one of the chemotherapies for advanced colorectal cancer.

Depth of mesorectal invasion has prognostic significance in T3N0 low rectal cancer

BACKGROUND/AIMS

To investigate mesorectal fat invasion as a prognostic factor for T3N0 low rectal adenocarcinoma following sharp mesorectal excision.

METHODOLOGY

Subjects consisted of 26 patients who had a potential curative excision of a T3N0 low rectal adenocarcinoma without neoadjuvant therapy between August 1988 and April 2003. Histological preparations were used to measure depth of mesorectal invasion, which was analyzed for associations with disease-free survival and recurrence.

RESULTS

Five-year overall survival and disease-free survival were 64.8% and 57.1%, respectively. Ten patients developed recurrent disease; 3 had local recurrence, 3 had distant metastasis, and 4 had both local and distant recurrence. Rectal cancers were stratified by depth of mesorectal invasion using 4 cutoff values (2, 3, 4, 5 mm), and examined by Cox proportional hazard model. At a cutoff of 3 mm, multivariate analyses confirmed depth of mesorectal invasion to be an independent prognostic factor for 5-year disease-free survival (< 3mm, 90.9%; > or = 3mm, 32.0%; p = 0.023). Distant metastasis differed significantly (< 3mm, 0%; > or = 3mm, 46.7%; p = 0.01), but local recurrence did not (< 3 mm, 9.1%; > or = 3mm, 40%; p = 0.17).

CONCLUSIONS

Patients with advanced low T3N0 rectal cancer are at high risk of distant metastases. Depth of mesorectal invasion may be valuable in decisions regarding intensive adjuvant therapy.

Progression from macular retinoschisis to retinal detachment in highly myopic eyes is associated with outer lamellar hole formation

Aims:

To investigate the morphological changes that occur during the development of an early retinal detachment (RD) from a myopic macular retinoschisis (MRS) by optical coherence tomography (OCT).

Methods:

The OCT images of five eyes of five consecutive patients with myopic MRS who developed an RD during the follow-up period were studied.

Results:

The progression from MRS to early RDs went through four stages. In stage 1, OCT images appeared to show a focal irregularity of the thickness of external retina. In stage 2, an outer lamellar hole developed within the thickened area and a small RD developed. In stage 3, the column-like structures overlying the hole seemed to be separated horizontally, and the outer lamellar hole appeared to be larger vertically. In stage 4, the upper edge of the external retina was further elevated and attached to the upper part of the retinoschisis layer accompanied by further enlargement of the RD.

Conclusions:

This longitudinal study showed that the progression from myopic MRS to RD passes through four stages, and the formation of an outer lamellar hole predisposes the retina to a RD. These OCT findings might be useful for considering the surgical indication for eyes with a myopic MRS.

Involvement of oxidative stress in experimentally induced reflux esophagitis and esophageal cancer

BACKGROUND/AIMS

Recent studies have demonstrated that refluxed duodenal contents cause esophageal carcinoma in rats without exposure to carcinogens. Oxidative damage has long been related to carcinogenesis in human cancers and animal cancer models. The purpose here was to investigate the pathogenesis of esophageal cancer in the experiment of chronic duodenal content reflux without carcinogen.

METHODOLOGY

Thirty 8-week-old male Wistar rats were exposed to duodenal content esophageal reflux. All animals underwent an esophagoduodenal anastomosis (EDA) with total gastrectomy in order to produce chronic esophagitis. In 10 rats the sham operation induced a midline laparotomy alone (Control). A total of 37 of 40 (92.5%) rats completed the study. In the EDA group, 27 (90%) rats completed the study. In the control group, 10 (100%) rats completely the study. They were sacrificed at the 35th week. Their esophagi were examined for the presence of cancer, Barrett's esophagus (BE), columnar line epithelium (CLE) and oxidative stress.

RESULTS

After 35 weeks of reflux, columnar dysplasia and squamous carcinoma were found. PCNA labeling index was higher in dysplastic and cancer tissue than that of normal. To discover the role of oxidative stress and radical scavenger capacity in the malignant transformation of Barrett's esophagus, we measured Malondialdehyde (MDA), Superoxide dismutase (SOD) activity and Glutathione (GSH) content in EDA rats. Mucosal MDA levels were significantly increased in EDA groups compared with the normal controls. GSH and SOD levels were significantly decreased in EDA group compared with the normal control group.

CONCLUSIONS

We proposed that oxidative damage plays an important role in the formation of esophageal cancer with EDA model.

Idiopathic nodular glomerulosclerosis: three Japanese cases and review of the literature

Idiopathic nodular glomerulosclerosis (ING) is characterized as diffuse nodular glomerulosclerotic lesions, closely resembling Kimmelstiel-Wilson lesions without diabetic mellitus. We report here three Japanese cases of ING and discuss the previous reports. The patients were 75-, 48- and 84-year-old males with a history of long-term hypertension. Laboratory examination revealed moderate proteinuria and mild renal dysfunction. Diabetes mellitus was excluded by repeated clinical and laboratory investigations. Renal histology revealed nodular glomerulosclerosis, and both afferent and efferent arteriolosclerosis in all patients. In electron microscopy, the glomerular basement membrane was markedly thick in all patients. A low-protein diet and potent anti-hypertensive treatment using angiotensin-converting enzyme inhibitors were initiated in all patients and urinary protein excretion significantly reduced without the progression of renal dysfunction. We reviewed 42 previously reported cases and our three cases. The analysis revealed that common clinical features of ING are being male (82.2%) of relatively advanced age (mean age 61.3 years), with hypertension (82.2%), mild renal dysfunction (mean serum creatinine 2.9 mg/dl) and moderate urinary protein excretion (mean 4.05 g/day). Common histopathological findings of ING are nodular glomerulosclerosis (100%), arterio-arteriolosclerosis (91.2 and 89.7%) and glomerular basement membrane thickening (85.7%). In conclusion, ING is one of the phenotypes of arteriosclerotic renal disease without diabetes mellitus. Severe arterio-arteriolosclerosis may contribute to the progression to glomerular nodular formation in ING. The combination of renin-angiotensin system inhibition and a low protein diet can be beneficial for the reduction of urinary protein excretion.

Long-term functional changes after low anterior resection for rectal cancer compared between a colonic J-pouch and a straight anastomosis

BACKGROUND/AIMS

We prospectively compared changes in function between colonic J-pouch and straight anastomoses from 1 to 5 years after low anterior resection for rectal cancer.

METHODOLOGY

At 1, 3, and 5 years after surgery, functional outcome was compared between 48 patients with J-pouch reconstruction (J group) and 51 with straight anastomosis (S group), using a 17-item questionnaire (overall best, 0; overall worst, 26). Reservoir function was evaluated manovolumetrically.

RESULTS

At 5 years, patients with ultralow anastomoses (< or =4 cm from anal verge) had fewer bowel movements during day or night, and less urgency and soiling in the J than S group. At that time, patients with low anastomoses (5 to 8 cm above the verge), had fewer bowel movements at night and less urgency in the J than S group. Manovolumetric results were better in the J than S group for both anastomotic levels. Functional scores improved significantly over time for both anastomotic levels, especially in the S group. Mean scores with ultralow anastomoses were J-group, 5.6 at 1 year vs. 5.3 at 3 years (P = 0.0304) vs. 3.7 at 5 years (P < 0.0001); and S group, 10.2 at 1 year vs. 9.6 at 3 years (P = 0.0063) vs. 7.3 at 5 years (P < 0.0001). Mean scores with low anastomoses were J group, 3.4 at 1 year vs. 3.1 at 3 years (P = 0.0052) vs. 2.1 at 5 years (P = 0.0003); and S group, 5.2 at 1 year vs. 3.8 at 3 years (P < 0.0001) vs. 2.7 at 5 years (P < 0.0001). Manovolumetric results improved overtime in both groups.

CONCLUSIONS

Functional outcome improved in the J and especially the S group over 5 years. However, function was better in the J than S group at all time points.

Cytoplasmic antineutrophil cytoplasmic antibody positive pauci-immune glomerulonephritis associated with infectious endocarditis

Renal deterioration often occurs in cases of infectious endocarditis (IE), but, IE- associated nephritis with rapidly progressive glomerulonephritis (RPGN) is rare. Patients with severe infection (e.g., IE) sometimes show positivity for cytoplasmic antineutrophil cytoplasmic antibodies (C-ANCA). Therefore, diagnosis and treatment are very difficult in cases of RPGN with IE and positivity for C-ANCA. Such cases are rare, only 12 have been reported in the English literature. Herein, we describe the case of a 50-year-old man who presented with RPGN with IE and tested positively for C-ANCA. He was referred to our hospital because of leg edema, purpura and renal dysfunction. Laboratory tests revealed serum creatinine elevation and positivity for C-ANCA and proteinase 3-specific (PR3)-ANCA. RPGN and acute renal failure were diagnosed. Hemodialysis and steroid therapy were started. Streptococcus oralis was isolated by blood culture. Transthoracic echocardiography revealed grade III mitral valve insufficiency with two vegetations. Therefore, IE was diagnosed. The steroid therapy was stopped, and antibiotic therapy was begun. Because there was no improvement, surgical therapy was performed. The operation was successful, but the patient died of brain hemorrhage. Our experience in this case indicates C/PR3-ANCA positive RPGN must be ruled out in patients with infectious disease, particularly IE, together with renal symptoms, and renal biopsy should be performed.

Long-Term Functional Outcome of Colonic J-pouch Reconstruction After Low Anterior Resection for Rectal Cancer

PURPOSE

To evaluate the long-term functional outcome of colonic J-pouch reconstruction after low anterior resection (LAR) for rectal cancer in a prospective study.

METHODS

We compared the functional outcome of 46 patients who underwent J-pouch reconstruction (J-group) and 49 patients who underwent straight anastomosis (S-group) after LAR for rectal cancer. We evaluated clinical function using a 17-item questionnaire about different aspects of bowel function. Physiologic reservoir function was evaluated by manovolumetry.

RESULTS

Among the patients with an ultralow anastomosis (<or=4 cm from the anal verge), those in the J-group had fewer bowel movements during the day and at night, and less urgency, soiling, protective pad use, incontinence, and dissatisfaction with bowel function than those in the S-group. Among the patients with a low anastomosis (5-8 cm from the verge), those in the J-group had fewer bowel movements at night, and less urgency and soiling than those in the S-group. Moreover, reservoir function (reflected by the maximum tolerable volume, threshold volume, and compliance) was better in the J-group than in the S-group in both the ultralow and low anastomosis groups.

CONCLUSION

J-pouch reconstruction after low anterior resection creates a better stool reservoir than straight anastomosis, especially when the anastomosis is less than 4 cm from the anal verge, resulting in a better quality of life 3 years after rectal cancer resection.

Optimal ligation level of the primary feeding artery and bowel resection margin in colon cancer surgery: the influence of the site of the primary feeding artery

PURPOSE

In colon cancer surgery, it is recommended that en bloc resection involving extended lymphadenectomy, characterized as a hemicolectomy, be performed by ligating the primary feeding artery at a high position and resecting proximal and distal with 5-cm to 10-cm bowel margins. However, there is little evidence to unequivocally support such extensive lymphovascular resection.

METHODS

The distribution of nodal metastases was obtained by the clearing method in 164 patients with colon cancer.

RESULTS

For pericolic spread, for pT1 tumors, the distance from the primary tumor to a diseased node was 2.5 cm; for pT2, the distance was less than 5 cm; for 97.0 percent of pT3 tumors and 93.3 percent of pT4 tumors with nodes involved, the distance was less than 7 cm. For central spread, for pT1 tumors, the rate of spread to central nodes was 0 percent; for pT2, the rate of spread was 20.0 percent to intermediate nodes (for tumors more than 5 cm from the feeding artery, the rate for central nodes was 0 percent); for pT3, the rate was 30.6 percent to intermediate nodes and 15.3 percent to main nodes; for pT4, the rate was 44.4 percent to intermediate nodes and 22.2 percent to main nodes. For curative resection cases with pT3 tumors more than 7 cm from the feeding artery, the rate to central nodes was 0 percent.

CONCLUSIONS

In T1 tumors, central node dissection is not required, but resection with proximal and distal 3-cm margins are required; in T2, central node dissection that includes the intermediate node should be performed in addition to resection with proximal and distal 5-cm margins. In T3 and T4, central node dissection that includes the main node should be performed in addition to resection with proximal and distal 7-cm margins. However, for T2 more than 5 cm from the primary feeding artery, and for T3 more than 7 cm from the primary feeding artery, proximal and distal resection alone may be adequate.

Number versus distribution in classifying regional lymph node metastases from colon cancer

BACKGROUND

Metastasis to regional lymph nodes from colon cancer is an important prognostic factor. In the TNM classification, node metastases are classified into three grades based on the number of metastatic nodes. In the Japanese General Rules for Clinical and Pathologic Studies on Cancer of the Colon, Rectum, and Anus (JGR), node metastases are classified into four grades based on the distribution of metastatic nodes.

STUDY DESIGN

Based on the findings of node metastases in 164 patients with colon cancer obtained by the clearing method, node classifications by the JGR and TNM classifications were compared.

RESULTS

The case distribution by the JGR grading was 41.5% in n (-), 29.3% in n1 (+), 18.3% in n2 (+), and 11.0% in n3 (+) disease. In the TNM classification, the distribution was 23.8% in pN1 and 34.8% in pN2 disease. The 5-year survival rate by the JGR was 98.4% in n (-), 74.3% in n1 (+), 51.2% in n2 (+), and 30.0% in n3 (+) disease; in TNM classification, this rate was 76.0% in pN1 and 45.0% in pN2 disease.

CONCLUSIONS

In the classification of regional node metastases from colon cancer, the JGR classification showed a wider range in distribution and 5-year survival rate compared with the TNM system.

Comparison of long-term functional results of colonic J-pouch and straight anastomosis after low anterior resection for rectal cancer: a five-year follow-up

PURPOSE

Few reports on the long-term functional outcome of colonic J-pouch reconstruction have been published, and data comparing J-pouch and straight reconstruction are contradictory. This prospective study compares the functional outcome of colonic J-pouch and straight anastomosis five years after low anterior resection for rectal cancer.

METHODS

Functional outcome was compared in 46 patients with J-pouch reconstruction (J-group) and 48 patients with straight anastomosis (S-group). Clinical status was evaluated with a 17-item questionnaire inquiring about different aspects of bowel function. Reservoir function was evaluated by manovolumetry. The Fisher's exact test and Wilcoxon's rank-sum test were used to compare categoric and quantitative data, respectively.

RESULTS

Among patients with an ultralow anastomosis (< or = 4 cm from the anal verge), the number of bowel movements during the day (> or = 5, 4.3 vs. 29.2 percent; P = 0.028) and at night (> 1/week, 4.3 vs. 33.3 percent; P = 0.013) and urgency (4.3 vs. 33.3 percent; P = 0.013) and soiling (21.7 vs. 50.0 percent; P = 0.043) were less in the J-group than in the S-group. Among patients with a low anastomosis (5 to 8 cm from the verge), patients in the J-group had fewer bowel movements at night (> 1/week, 0 vs. 20.8 percent; P = 0.028) and less urgency (0 vs. 20.8 percent; P = 0.028). Reservoir function was better in the J-group than in the S-group in both the ultralow (maximum tolerable volume (mean), 101.7 vs. 76.3 ml; P = 0.004; threshold volume (mean), 46.5 vs. 30.4 ml; P < 0.001; compliance (mean), 4.9 vs. 2.5 ml/cm H2O; P < 0.001) and low-anastomosis (maximum tolerable volume, 120.4 vs. 97.9 ml; P < 0.001; threshold volume, 58.3 vs. 40.8 ml; P < 0.001; compliance, 5.2 vs. 3.1 ml/cm H2O; P < 0.001) groups.

CONCLUSIONS

J-pouch reconstruction increased reservoir function and provided better functional outcome than straight anastomosis, even five years after surgery, especially in patients whose anastomosis is less than 4 cm from the anal verge.

Long-term functional outcome of low anterior resection with colonic J-pouch reconstruction for rectal cancer in the elderly

PURPOSE

Bowel function after low anterior resection for rectal cancer with colonic J-pouch reconstruction is more normal than after conventional straight anastomosis. However, few reports have examined the function of colonic J-pouch reconstruction in the elderly. Good function would obviate the need for colostomy, which is sometimes performed because of concern about fecal incontinence, which increases with age. This study evaluated the function of colonic J-pouch reconstruction in elderly patients aged 75 years or older.

METHODS

Functional outcome was compared in 20 patients aged 75 years or older (older group) and 27 patients aged 60 to 74 years (old group) and 60 patients aged 59 years or younger (young group), 3 years after colonic J-pouch reconstruction, using a functional scoring system with a 17-item questionnaire (score range, 0 (overall good) to 26 (overall poor)).

RESULTS

The functional scores in the three age groups were satisfactory and similar. Among patients with anastomoses 1 cm to 4 cm from the anal verge, all 17 categories on the questionnaire in the three age groups were similar. Among patients with anastomoses 5 cm to 8 cm from the anal verge, only the use of laxatives or glycerine enemas was more common in the older group than in the old and young group (90 vs. 38.5 percent and 43.3 percent; P = 0.01).

CONCLUSIONS

Low anterior resection with colonic J-pouch reconstruction provides excellent functional outcome, including continence, for elderly patients. Colonic J-pouch reconstruction is a highly preferable alternative to permanent colostomy in elderly patients undergoing low anterior resection.

Peripapillary crescent enlargement in highly myopic eyes evaluated by fluorescein and indocyanine green angiography

AIMS

To evaluate angiographic features of myopic crescents using fluorescein angiography (FA) and indocyanine green angiography (IA).

METHODS

FA and IA angiograms of 88 highly myopic eyes (47 consecutive patients) were reviewed. The follow up period ranged from 5-28 years.

RESULTS

FA revealed two zones of the myopic crescent: a consistently hypofluorescent inner zone and an outer zone with delayed choroidal filling. IA revealed dislocation of the Zinn-Haller ring to the border between the two zones. Myopic crescent enlargement occurred in 68.1%. Only the outer zone increased significantly in most of the eyes with enlarged crescents.

CONCLUSIONS

The inner zone might develop as a result of mechanical stretching, and the outer zone might be the result a secondary circulatory disturbance and mechanical stretching.

Patchy atrophy and lacquer cracks predispose to the development of choroidal neovascularisation in pathological myopia

AIMS

To determine the incidence and predisposing findings for choroidal neovascularisation (CNV) in a large series of highly myopic patients.

METHODS

The medical records of 218 consecutive patients (325 eyes) with myopic fundus changes in the macula were reviewed. The incidence of CNV during a follow up of at least 3 years of highly myopic patients and identification of predisposing findings for the development of myopic CNV were examined.

RESULTS

Among 325 highly myopic eyes examined, 33 eyes (10.2%) developed myopic CNV. The incidence was higher (34.8%) among the fellow eyes of patients with pre-existing CNV than among eyes of patients without pre-existing CNV (6.1%). CNV developed in 3.7% with diffuse chorioretinal atrophy, in 20.0% with patchy atrophy, and in 29.4% with lacquer cracks.

CONCLUSION

Approximately one in 10 highly myopic eyes developed myopic CNV in average 130.2 months. Patchy atrophy and lacquer cracks were shown to be important predisposing findings for CNV development.

Visual deprivation stimulates the exchange of the fibrous sclera into the cartilaginous sclera in chicks

Form deprivation myopia in chicks is a widely accepted model to study visually-regulated postnatal ocular growth. The chick sclera has a cartilaginous layer as well as the fibrous layer found in mammals. It appears that a dynamic relationship exists between these two layers during visual deprivation-induced growth. The changes in the fibrous sclera of myopic eyes, however, have not been previously described. This investigation is focused on the comparative morphological analyses of the cartilaginous and fibrous scleral changes in myopic chick eyes. The fibrous scleral changes in the posterior segment of myopic eyes were examined in detail using light and electron microscopy, and the expression of growth factors was analysed by immunohistochemistry. In the posterior segment of myopic eyes the border between the cartilaginous and fibrous layers was indistinct because of collagen bundles of the fibrous sclera that spread into the cartilaginous sclera, whereas in control eyes the distinction was clear. Various types of transitional cells, from fibroblast-like mesenchymal cells to chondrocytes, were found in the border between the cartilaginous and fibrous layers. Collagen fibrillar diameters of the fibrous sclera in the posterior segment of myopic eyes were smaller than in control, whereas those in the equatorial segment were almost the same in myopic and control eyes although the distribution of sizes was obviously different. Thus, changes in the fibrous sclera in myopic eyes of chicks seem to be similar to scleral changes in myopic eyes of mammals. The cells in the posterior sclera of myopic eyes were more intensely immunostained for TGF-beta and IGF-II than control, whereas no immunoreaction of TGF-alpha could be detected in either control or myopic eyes. These results suggest that the structural characteristics of the posterior sclera are different from those of the anterior and equatorial segments. Undifferentiated mesenchymal cells might be concentrically distributed exclusively in the innermost layer of posterior fibrous sclera. TGF-beta and IGF-II might influence cell growth, differentiation, and migration in the exaggerated scleral growth accompanying myopia.

The quality of life in patients with pathologic myopia

PURPOSE

To evaluate the functional status in daily life and the quality of life (QOL) of pathologic myopia patients.

METHODS

A cross-sectional study was conducted using data of consecutive pathologic myopia patients (n = 200) and control subjects (n = 144). The influence of the disease on the daily life and the QOL of patients were evaluated using a self-rated questionnaire. The questionnaire covered the full range of daily life activity, including daily tasks depending on visual acuity, social and emotional handicaps, and cognition of disease, and the QOL of pathologic myopia patients.

RESULTS

The functional status in daily life and the QOL of patients were reduced compared with control subjects. The influence of pathologic myopia on a patient's daily life was primarily the result of three major factors, handicap, disability, and support. All three factors correlated with the QOL, the degree of handicap having the strongest correlation.

CONCLUSION

The functional status in daily life and the QOL of pathologic myopia patients were reduced; this decline in QOL was attributed to handicap and disability caused by the ocular disease.

Blue light-induced apoptosis in cultured retinal pigment epithelium cells of the rat

BACKGROUND

We previously demonstrated that phagosome-free retinal pigment epithelium (RPE) cells in culture can be damaged directly by blue light (wavelength 440+/-10 nm) as observed by electron microscope. A low intensity (1.0 mW/cm2) of light induced only swelling of mitochondria, while a high intensity (4.0 mW/cm2) induced necrosis in the RPE. The aim of the present study was to investigate what intensity of blue light could induce apoptosis in cultured phagosome-free RPE.

METHODS

Primary cultured RPE cells, harvested from Long-Evans rats, that contained no phagosomes were exposed to a cool blue light (wavelength 440+/-10 nm). After exposure, transmission electron microscopy (TEM) and TdT-mediated dUTP nick-end labeling (TUNEL) staining were used to detect apoptosis in the RPE cells. To assess the relationship of oxidation to apoptosis by blue light, we added N-acetylcysteine (NAC) as a free radical scavenger and investigated its inhibitory effect on apoptosis.

RESULTS

In RPE cells exposed to blue light of 2.7 mW/cm2 for 24 h, apoptotic bodies were found by TEM. In RPE cells exposed to blue light of 2.0 mW/cm2 for 60 h, apoptotic bodies, nuclear condensation and nuclear segmentation were observed by TEM and some RPE cells showed positive TUNEL staining. When 30 mM of NAC was added, TUNEL staining was negative.

CONCLUSION

Our findings demonstrate that apoptotic cell death is induced by blue light exposure in cultured RPE cells in vitro. The findings of our previous experiments and those of the present study suggest that a higher intensity of blue light could induce necrosis, and moderately intense blue light could induce non-necrotic cell death or apoptosis, in RPE cells. Furthermore, it is suggested that blue light caused cell death by a free-radical-associated mechanism.

Clinical course of newly developed or progressive patchy chorioretinal atrophy in pathological myopia

Regional chorioretinal atrophy in the posterior fundus (patchy chorioretinal atrophy) in pathological myopia impairs vision severely when it covers the macula. The aim of this study was to assess the course of development and progression of patchy chorioretinal atrophy in pathological myopia. The location and progression of patchy chorioretinal atrophy that was either newly developed or had progressed during the follow-up period (mean 5.25 years) were analyzed. A total of 41 lesions of patchy atrophy were newly developed in 30 eyes of 25 patients. These lesions were more likely to occur in marginal regions of a posterior staphyloma but frequency per unit area was highest in the macula. There were 138 lesions of patchy chorioretinal atrophy that progressed in 75 eyes of 53 patients. Sixty percent of the lesions of patchy chorioretinal atrophy in marginal regions of a posterior staphyloma spread toward the center. Seventy percent of the lesions of patchy chorioretinal atrophy in the macula spread in all directions. Fluorescein angiography of newly developed patchy chorioretinal atrophy showed hyperfluorescence in 50% and hypofluorescence in 27%. Fluorescein angiography of progressive lesions of patchy chorioretinal atrophy showed hypofluorescence in 69%. Fluorescein angiography of some progressive areas of patchy chorioretinal atrophy, which showed a change from hyperfluorescence to hypofluorescence within several years, suggested that damage to the retinal pigment epithelium preceded the progression of the patchy chorioretinal atrophy. In conclusion, the patchy chorioretinal atrophy is most likely to occur in the macula and to enlarge in all directions. And it is suggested that the patchy chorioretinal atrophy which shows hyperfluorescence by fluorescein angiography should be kept under observation because our data suggest that this finding indicates progression in the future.

[Peripapillary fluorescein angiographic findings in non-glaucomatous eyes]

PURPOSE

In fluorescein angiography (FAG), glaucomatous eyes show a zone of no fluorescence around the disc and hyperfluorescence indicating serum diffusion at the margin of the zone, which play some role in glaucomatous optic nerve damage. But detailed FAG findings have not been reported in non-glaucomatous eyes. We conducted a study to investigate whether peripapillary FAG findings in glaucomatous eyes were specific to glaucoma or not.

MATERIALS AND METHODS

46 eyes of 46 subjects were selected by some reservations from all the non-glaucomatous patients undergoing FAG in 1996. We studied FAG films and measured the zone of no fluorescence adjacent to the disc (non-fluorescent zone).

RESULT

44 eyes (95.6%) showed a non-fluorescent zone. The non-fluorescent zone was clearly wider in temporal sectors than nasal sectors, and its width was related to the refraction. There were two types of non-fluorescent zone, one showing hyperfluorescence from the outer boundary of the zone in the late phase, and the other showing hyperfluorescence from the disc margin. The width of the non-fluorescent zone in the former type was wider than in the latter type. These results are similar to the findings in glaucomatous eyes.

CONCLUSION

These findings suggest that not only glaucomatous eyes but also non-glaucomatous eyes have a variety of histological structures and serum diffusion around the disc.

Retinoic acid increases in the retina of the chick with form deprivation myopia

We previously reported that expression of retinoic acid receptor beta increases in the sclera of the 2-week-old chick with form deprivation myopia (FDM) and that all-trans-retinoic acid (t-RA) influences proliferation and differentiation of scleral cells. The purpose of this study was to quantify t-RA in the retina of the chick with FDM and to investigate the role of t-RA in FDM in the chick. FDM was induced in 2-day-old chicks by placement of a translucent plastic goggle over one eye, with the contralateral eye used as a control. After 5 days, the chicks were sacrificed. t-RA was extracted from neural retina and served for high-performance liquid chromatography analysis. 3H-t-RA was used for normalization. Pieces of the retinae from 5 eyes served as one sample. As a result, t-RA was 09.60 +/- 0.86 ng/eye (0.387 +/- 0.056 ng/mg protein) in the myopic retina was significantly higher than that in the control (p < 0.05, n = 7). These results demonstrate that t-RA increases in the retina within 5 days after visual deprivation. This finding suggests that t-RA may play a role in the metabolic changes in FDM.