[A Case of Rhabdomyolysis Caused by Oxaliplatin during Postoperative Adjuvant Chemotherapy]

The patient was a 50-year-old male. At the age of 48 years, he had undergone total gastrectomy and right hemicolectomy simultaneously for gastric and ascending colon cancers. Since adjuvant chemotherapy has become common practice for patients with ascending colon cancer, capecitabine was administered for 6 months. One year and 6 months after the surgery, he was diagnosed with recurrence of the ascending colon cancer at the anastomotic site and underwent local colectomy. Considering he was pathologically diagnosed as pT4a, mFOLFOX6 therapy was prescribed as postoperative adjuvant chemotherapy. On the day the 11th course of treatment was initiated, the patient complained of weakness; however, his blood test results showed no abnormalities; therefore, he was followed-up as an outpatient. Three days later, he presented to the hospital with exacerbated symptoms and was diagnosed with rhabdomyolysis due to a marked increase in CK(2,031 U/L). Rhabdomyolysis was determined to be the adverse effect of oxaliplatin because out of all the drugs prescribed to the patient, this condition is listed as a side effect only in oxaliplatin's package insert. Fortunately, outpatient treatment was enough to alleviate rhabdomyolysis. Subsequently, adjuvant chemotherapy was completed without oxaliplatin. The patient has been followed-up without recurrence for 9 months after the surgery.

[A Case of Transverse Colon Cancer Complicated by Eosinophilic Granulomatosis with Polyangiitis]

A man in his 50s had undergone steroid therapy for eosinophilic granulomatosis with polyangiitis(EGPA). Since an examination for malignant tumors revealed type 0-Ⅰsp(cT1aN0M0)and type 2(cT2N0M0)lesions in the proximal and mid- transverse colon, respectively, he was referred to our department. Endoscopic resection was performed on the proximal lesion. After the confirmation of curative resection, laparoscopic partial colectomy(transverse colon)and D3 lymph node dissection were performed on the mid-transverse lesion. Because of the patient's favorable postoperative course, he was discharged from the hospital on POD17. Since steroids and immunosuppressants may cause immunological abnormalities and malignant tumors, such patients should be strictly followed up.

[A Case of Extramural Growth-Type Ileocecal Colon Cancer]

A woman in her 80s was diagnosed with an abdominal mass during physical examination. Contrast-enhanced computed tomography(CT)revealed a tumor with contrast enhancement outside the ileocecal region of the intestine, and the ileocolic artery penetrated the tumor. No tumor was detected by colonoscopy. An endoscope could not be passed through due to an ileocecal valve stenosis. A biopsy of the ileocecal valve revealed only lymphocyte hyperplasia without adenocarcinoma components. Barium enema examination demonstrated no influx of the contrast medium from the cecum into the oral side of the intestine. Since a gastrointestinal stromal tumor in the ileocecal region was suspected, laparotomy was performed in the ileocecal region owing to the preoperative diagnosis of suspected malignant lymphoma, revealing a 5-cm elastic hard tumor outside the ileocecal wall. The tumor could not be separated from the intestinal tract. Histopathological examination revealed no lesion on the mucosal surface, although poorly differentiated adenocarcinoma infiltrated from the submucosa to the serosa. Thus, the patient was diagnosed with extramural growth-type ileocecal colon cancer. This disease is relatively rare but need to be kept in mind.

Usefulness of a Precursory Small Epigastric Midline Incision during Laparoscopic Right Hemicolectomy

Objectives:

During laparoscopic right hemicolectomy, many surgeons make a small incision near the umbilicus after the routine intraperitoneal operation. In this study, we created a precursory small epigastric incision at the center of a line connecting the xiphoid process and umbilicus (the M point, an empirically determined position) at the start of surgery prior to laparoscopic manipulation. This study aimed to determine whether the small incision at the center of the M point was a suitable position through which the right hemicolon is extracted.

Methods:

The subjects included 148 patients who underwent laparoscopic right hemicolectomy at our hospital between January 2013 and December 2019. We measured the distance between the M point and the gastrocolic trunk (GCT) root at the base of the transverse mesocolon and the middle colic artery (MCA) root on preoperative contrast-enhanced computed tomography images.

Results:

We found that the GCT and MCA roots are located within a radius of 1.5 cm from the M point, suggesting that the base of the transverse mesentery was located almost directly below the M point. Comparisons based on sex differences and body mass index (BMI) also revealed that the transverse mesocolon root is closer to the M point in men and overweight patients.

Conclusions:

From these results, the placement of a precursory small epigastric midline incision not only allows for a safe insertion of the first laparoscopic port in a short period of time but also facilitates safe transection and anastomosis due to the proximity of the M point to the transverse mesocolon root.

Identification of patient subgroups with unfavorable long-term outcomes associated with laparoscopic surgery in a randomized controlled trial comparing open and laparoscopic surgery for colon cancer (Japan Clinical Oncology Group Study JCOG0404)

BACKGROUND

Previously, we conducted a randomized controlled trial (JCOG0404) for stage II/III colon cancer patients and reported that the long-term survival after open surgery (OP) and laparoscopic surgery (LAP) were almost identical; however, JCOG0404 suggested that survival of patients after LAP with tumors located in the rectosigmoid colon, cT4 or cN2 tumors, and high body mass index (BMI) might be unfavorable.

AIM

To identify the patient subgroups associated with poor long-term survival in the LAP arm compared with the OP arm.

METHODS

Patients aged 20-75, clinical T3 or deeper lesion without involvement of other organs, clinical N0-2 and M0 were included. The patients with pathological stage IV and R2 resection were excluded from the current analysis. In each subgroup, the hazard ratio for LAP (vs. OP) in overall survival (OS) from surgery was estimated using a multivariable Cox regression model adjusted for the clinical and pathological factors.

RESULTS

In total, 1025 patients (OP, 511 and LAP, 514) were included in the current analysis. Adjusted hazards ratios for OS of patients with high BMI (>25 kg/m2), pT4, and pN2 in LAP were 3.37 (95% confidence interval [CI], 1.24-9.19), 1.33 (0.73-2.41), and 1.74 (0.76-3.97), respectively. In contrast, that of rectosigmoid colon tumors was 0.98 (0.46-2.09).

CONCLUSIONS

Although LAP is an acceptable optional treatment for stage II/III colon cancer, the present subgroup analysis suggests that high BMI (>25 kg/m2), pT4, and pN2 except for RS were factors associated with unfavorable long-term outcomes of LAP in patients with colon cancer who underwent curative resection. (JCOG 0404: NCT00147134/UMIN-CTR: C000000105.).

Risk factors for anastomotic leakage after laparoscopic surgery with the double stapling technique for stage 0/I rectal carcinoma: a subgroup analysis of a multicenter, single-arm phase II trial

PURPOSE

The aim of this study was to determine the risk factors for anastomotic leakage after laparoscopic rectal surgery.

METHODS

We conducted a prospective trial involving 395 patients with stage 0/I rectal carcinoma who underwent laparoscopic low anterior resection using a double stapling technique. Data concerning variables related to patient background, tumors and surgical factors were evaluated. The outcomes with respect to anastomotic leakage were recorded, and univariate and multivariate analyses were performed to identify relevant risk factors.

RESULTS

The overall anastomotic leakage rate was 8.4%. A univariate analysis showed male gender (P = 0.006) and preoperative blood sugar level (P = 0.0034) to be significantly associated with anastomotic leakage. The variables of gender, preoperative blood sugar level, American Society of Anesthesiologists (ASA) classification (P = 0.15), transanal decompression tube (P = 0.06) and number of stapler cartridges used for rectal transection (P = 0.18) were selected for the multivariate analysis because of their P values being <0.2. The multivariate analysis identified male gender (odds ratio 4.12, P = 0.006) and the absence of a transanal decompression tube (odds ratio 3.11, P = 0.0484) as independent risk factors predicting anastomotic leakage.

CONCLUSIONS

Male gender and the absence of a transanal decompression tube appeared to be independent risk factors for anastomotic leakage. Insertion of a transanal decompression tube may help prevent anastomotic leakage after low anterior resection, particularly in male patients.

Flattened tumor requires a more careful attention for residual distal cancer spread in locally advanced lower rectal carcinoma after chemoradiotherapy

BACKGROUND/AIMS

Limited data are available on distal resection margin (DRM) for lower rectal cancer (LRC) after preoperative chemoradiotherapy (pre-CRT); thus, we aimed to establish the criteria for DRMs as estimated by the macroscopic tumor appearance.

METHODS

This was a pathological study using whole-mount sections that included the entire circumference of tumor. Residual cancer spread located most distally from the macroscopic tumor border was mainly evaluated.

RESULTS

A retrospective cohort of 42 consecutive patients with locally advanced LRC after pre-CRT was enrolled, and 38 patients were eligible for this study. According to the macroscopic tumor appearance, 18 patients had raised-type and 20 had flattened-type tumors. Patients with flattened-type tumors were closely associated with histopathological regression grade. Residual distal cancer spread (RDCS) was located ≤4.0 mm (median, 0.1 mm) in the raised-type tumors and ≤17.1 mm (median, 4.2 mm) in the flattened-type tumors. RDCS in flattened-type tumors was distributed diffusely and distally from the tumor border (p = 0.022).

CONCLUSION

Even in patients evaluated as pre-CRT responders, flattened tumors often accompanied distally located residual cancer that had spread from the tumor border and require more careful attention in order to ensure cancer clearance.

Laparoscopic resection for colorectal cancer improves short-term outcomes in very elderly colorectal cancer patients

BACKGROUND

Laparoscopic-assisted colectomy (LAC) for colorectal cancer has been shown to improve short-term outcomes compared with open colectomy (OC) in colorectal cancer patients. However, there are a few reports that describe the efficacy of LAC in the very elderly population. We investigated whether LAC improves short-term outcomes in elderly patients, especially those 80 years of age or older.

METHOD

Eighty-two consecutive elderly (80 years of age or older) patients who underwent either OC or LAC for colorectal cancer were reviewed. Continuous variables were analyzed by the Mann-Whitney U test. Categorical variables were compared by χ tests.

RESULTS

Of the 82 elderly patients with colorectal cancer, 34 patients underwent OC and 48 patients had LAC. There were no significant differences in postoperative complications between the 2 groups. LAC demonstrated less blood loss, fewer days on a liquid diet, and a shorter postoperative stay in the hospital than OC.

CONCLUSIONS

LAC improved short-term outcomes even in very elderly patients.

Perioperative outcomes of esophagectomy preceded by the laparoscopic transhiatal approach for esophageal cancer

This study was designed to determine the efficacy of esophagectomy preceded by the laparoscopic transhiatal approach (LTHA) with regard to the perioperative outcomes of esophageal cancer. The esophageal hiatus was opened by hand-assisted laparoscopic surgery, and carbon dioxide was introduced into the mediastinum. Dissection of the distal esophagus was performed up to the level of the tracheal bifurcation. En bloc dissection of the posterior mediastinal lymph nodes was performed using LTHA. Next, cervical lymphadenectomy, reconstruction via a retrosternal route with a gastric tube and anastomosis from a cervical approach were performed. Finally, a small thoracotomy (around 10 cm in size) was made to extract the thoracic esophagus and allow upper mediastinal lymphadenectomy to be performed. The treatment outcomes of 27 esophageal cancer patients who underwent LTHA-preceding esophagectomy were compared with those of 33 patients who underwent the transthoracic approach preceding esophagectomy without LTHA (thoracotomy; around 20 cm in size). The intrathoracic operative time and operative bleeding were significantly decreased by LTHA. The total operative time did not differ between the two groups, suggesting that the abdominal procedure was longer in the LTHA group. The number of resected lymph nodes did not differ between the two groups. Postoperative respiratory complications occurred in 18.5% of patients treated with LTHA and 30.3% of those treated without it. The increase in the number of peripheral white blood cells and the duration of thoracic drainage were significantly decreased by this method. Our surgical procedure provides a good surgical view of the posterior mediastinum, markedly shortens the intrathoracic operative time, and decreases the operative bleeding without increasing major postoperative complications.

A new approach to laparoscopic lymph node excision in cases of transverse colon cancer

BACKGROUND

Treatment of transverse colon cancer by laparoscopic surgery is difficult, and this surgery has been excluded in many randomized control trials. Difficulty in excising lymph nodes around the middle colonic artery has been the main factor responsible for the complexity of this surgery. Herein, we describe a new approach to overcome this difficulty in lymph node excision in cases of transverse colon cancer.

APPROACH

We adopted the following steps to collect information that was otherwise difficult to obtain from two-dimensional images displayed on the monitor screen, in order to ensure safety during laparoscopic surgery. (1) The omental bursa was opened by directly visualizing it through a small incision created in the median epigastric region, and the cranial side of the transverse colon mesentery was then freed. (2) The colonic drainage vein entering the right gastroepiploic vein was dissected, and a gauze was inserted into the freed layer. (3) Under laparoscopic guidance, the freed layer was fixed, with the inserted gauze serving as a landmark. The lymph nodes were then excised making full use of the horizontal view.

CONCLUSION

Utilization of a small incision in the abdomen enables full use of the horizontal view for manipulations during laparoscopy, allowing safe manipulations for lymph node excision.

Efficacy of 5-aminolevulinic acid-mediated photodynamic therapy using light-emitting diodes in human colon cancer cells

5-Aminolevulinic acid (ALA)-mediated photodynamic therapy (PDT) (ALA-PDT) is a highly selective treatment for malignant cells. ALA-PDT has the potential to develop into a novel therapeutic strategy for various types of cancer. Recently, light-emitting diodes (LEDs), which are inexpensive, stable and easier to handle compared to lasers, have been used in PDT as a light source. However, in colorectal cancer (CRC), the efficacy of ALA-PDT in combination with LEDs has not been fully assessed. Therefore, in this study, we evaluated the antitumor effect of ALA-PDT using various LEDs in colon cancer cells. The HT-29 human colon cancer cell line was used both in vitro and in vivo. HT-29 cells were seeded in 96-well plates. Following 5-ALA administration, cells were irradiated using LEDs at different wavelengths. Three types of LEDs, blue (peak wavelength, 456 nm), white (broad-band) and red (635 nm) were used. Twenty-four hours after irradiation, the cytotoxic effects of ALA-PDT were measured using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. In order to evaluate the antitumor effect of ALA-PDT in vivo, nude mice were inoculated with HT-29 cells. Xenograft mice were injected intraperitoneally with 5-ALA and irradiated with 3 types of LEDs at a measured fluence rate of 96 mW/cm² and fluence of 32 J/cm². Each group comprised 6 mice. ALA-PDT was repeated 3 times at weekly intervals. Tumor weights were measured. Compared to the controls, ALA-PDT using LEDs showed significant antitumor effects in vitro and in vivo. The blue and white LEDs demonstrated greater antitumor effects compared to the red LEDs in vitro and in vivo. In particular, tumor inhibition rates in the blue and white LED groups were approximately 88% to those of the control group in the mouse models. In conclusion, ALA-PDT using LEDs is effective and useful in the treatment of CRC cells. This method could be a novel treatment modality for CRC.

Incidentally Discovered Adenocarcinoma in situ of the Appendix in a Young Woman

Primary appendiceal adenocarcinoma is an infrequent disease. This report presents a rare case of incidentally discovered carcinoma in situ of the appendix. A 35-year-old parturient female simultaneously underwent appendectomy and oophorectomy due to an ovarian abscess that adhered to the appendix during cesarean section. Although her excised appendix showed no apparent tumorous lesion, histopathological examination revealed carcinoma in situ in the excised appendix. She underwent additional right hemicolectomy a few days later due to the possibility of a positive surgical margin. Histopathological examination detected no malignant cells in the resected specimen. She was discharged without any complications and has since remained healthy. Appendiceal adenocarcinoma is generally considered to be difficult to diagnose during the early stage because it seldom shows any specific findings. This results in a poor prognosis. Histopathological examination is not always conducted for appendices resected during other surgery. However, the current study suggests that a careful routine histopathological examination of excised appendix, as well as careful preoperative examination and detailed intraperitoneal inspection during surgery, is indeed important to detect occult appendiceal tumors.

Evaluation of lymph node metastasis in patients with gastric cancer: a comparison of the directionality of lymph node metastasis and the total number of metastatic lymph nodes

PURPOSE

The clinical impact of the directionality of lymph node (LN) metastasis was assessed in comparison with the staging by the Japanese Classification of Gastric Carcinoma (JCGC), a numerical LN staging system.

METHODS

Two hundred forty-one gastric cancer patients who were diagnosed pathologically to have LN metastasis, and 54 patients who underwent preoperative multidetector-row computed tomography (MDCT) with an image thickness of 1 mm were classified into three groups (unidirectional [Uni-], bidirectional [Bi-], and tridirectional [Tri-] groups) depending on the directionality of their LN metastasis.

RESULTS

The prognosis of the Uni-group was better than that of the Bi- or the Tri-group when assessed on the basis of the pathological findings of metastatic LN and also the preoperative MDCT findings. The exact preoperative evaluation was 70.2 % for the directionality system and 61.7 % for the JCGC system, respectively. The stages were less frequently underestimated by the directionality system than the JCGC system (P < 0.02, 19.1 vs. 34.0 %), and the staging could be more precisely performed by both systems in combination.

CONCLUSIONS

More precise preoperative evaluation of disease stage could be obtained by the directionality system and the JCGC system in combination.

HGF regulates VEGF expression via the c-Met receptor downstream pathways, PI3K/Akt, MAPK and STAT3, in CT26 murine cells

In the present study, we assessed the involvement of hepatocyte growth factor (HGF)/c-Met signalling with vascular endothelial cell growth factor (VEGF) and hypoxia inducible factor (HIF)-1α expression in the downstream pathways phosphatidylinositol 3-kinase (PI3K)/Akt, mitogen-activated protein kinase (MAPK) and signal transducer and activator of transcription 3 (STAT3) in CT26 cells, to determine the mechanisms of the potent anti-angiogenic effect of NK4. We established genetically modified CT26 cells to produce NK4 (CT26-NK4). VEGF expression in subcutaneous CT26 tumours in vivo and in culture supernatants in vitro was determined by ELISA. HIF-1α expression in nuclear extracts was evaluated by western blot analysis. VEGF and HIF-1α mRNA levels were examined by real-time reverse transcription-polymerase chain reaction (RT-PCR). The DNA binding activity of HIF-1α was evaluated using an HIF-1α transcription factor assay kit. Our results demonstrated that VEGF expression was reduced in homografts of CT26-NK4 cells, compared to those of the control cells. In vitro, VEGF expression, which was induced by HGF, was inhibited by anti-HGF antibody, NK4 and by kinase inhibitors (PI3K, LY294002; MAPK, PD98059; and STAT3, Stattic). HGF‑induced HIF‑1α transcriptional activity was also inhibited by the kinase inhibitors. Real-time RT-PCR demonstrated that HGF‑induced HIF‑1α mRNA expression was not inhibited by LY294002 and PD98059, but was inhibited by Stattic. These data suggest that the PI3K/Akt, MAPK and STAT3 pathways, downstream of HGF/c‑Met signalling, are involved in the regulation of VEGF expression in CT26 cells. HGF/c‑Met signalling may be a promising target for anti-angiogenic strategies.

Staging fluorescence laparoscopy for gastric cancer by using 5-aminolevulinic acid

BACKGROUND

Precise staging of gastric cancer is essential when selecting for the appropriate treatment approach. 5-Aminolevulinic acid (5-ALA) is metabolized and accumulated as protoporphyrin IX (PpIX), which is a photosensitizer. In this study, we evaluated the diagnostic usefulness of 5-ALA for demonstrating peritoneal dissemination in patients with gastric cancer.

MATERIALS AND METHODS

Fluorescence laparoscopy (FL) was performed in 13 patients with gastric cancer. All patients received preoperative oral administration of 5-ALA. Fluorescence-light laparoscopies were sequentially performed intraoperatively.

RESULTS

In four out of the 13 patients, primary tumors were detected by FL and demonstrated serosal invasion on histological examination. Five out of the 13 patients demonstrated peritoneal metastases, and one patient demonstrated superficial liver micrometastases, by FL. All of these lesions were diagnosed as metastatic lesions by hematoxylin and eosin staining.

CONCLUSION

These findings show that FL diagnosis with 5-ALA is accurate and suitable for the detection of peritoneal metastases and of superficial liver micrometastases in patients with gastric cancer.

[A novel treatment strategy using trafermin, containing basic fibroblast growth factor, for intractable duodenal fistula following curative gastrectomy for gastric cancer-case report and literature review]

Despite recent perioperative technological advances in gastric cancer treatment, duodenal stump leakage and intractable duodenal fistula are still major critical complications following gastrectomy that should be specifically targeted in order to improve postoperative outcomes. Here, we provide a preliminary report of a case of intractable duodenal fistula successfully treated with Trafermin containing basic fibroblast growth factor. A 70-year-old man underwent distal gastrectomy with radical lymphadenectomy for early distal gastric cancer (pT1bN0M0). After surgery, duodenal fistula occurred and persisted for 1 year and 2 months despite surgery and several conservative treatments. After obtaining informed consent, we started injection of Trafermin at 50 μg/day through a drainage tube into the dehiscence of the duodenum. Consequently, the duodenal fistula was successfully closed within 4 weeks. Our novel treatment technique is simple, rapid, and cost effective. If informed consent is obtained from patients with a low risk of recurrence, this technique should be recommended as one of the treatment choices for intractable duodenal fistula following curative gastrectomy for gastric cancer.

[The clinical influence of double or multiple primary cancers on the prognosis of patients with gastric cancer]

BACKGROUND

An aging population and advances in diagnostic technology have led to an increase in the incidence of double or multiple primary cancers(DMPC) in patients with gastric cancer(GC). This study was designed to evaluate the clinical influence of DMPC on the prognosis of patients with GC.

METHODS

Between 1997 and 2009, 1,086 patients underwent curative gastrectomy for GC in our hospital.

RESULTS

1) 1,086 patients were analyzed, and of these 166 patients (15%) had DMPC and the remaining 920 patients had no DMPC. GC patients with DMPC had a significantly higher age (p <0.0001) and higher incidence of differentiated cancer(p=0.0045) than those without DMPC. 2) Multivariate analysis showed the presence of DMPC was an independent prognostic factor for overall survival. It was particularly noteworthy that the prognosis of GC patients with hematological cancer, hepato-biliary pancreatic cancer and esophageal cancer was extremely poor. In contrast, those with colorectal cancer and urological cancer had a comparatively better prognosis. The number of DMPC had little influence on the prognosis of GC patients. 3) In a survival associated with GC, the presence of DMPC had no influence on the prognosis of GC patients.

CONCLUSIONS

The types of DMPC had more clinical influence on the prognosis of GC patients than the number of DMPC with respect to overall survival.

[Diagnostic value of direct inspection and palpitation by surgeons in intra-operative nodal staging of gastric cancer]

BACKGROUND AND PURPOSE

Recent imaging modalities such as multi-detector computed tomography, fluorodeoxyglucose positron emission tomography/computed tomography, and magnetic resonance imaging have emerged as promising diagnostic and staging methods in various cancers. However, these modalities lack the diagnostic ability to evaluate tissue elasticity, which could instead be easily estimated by a surgeon through palpitation. To add tissue elasticity to future diagnostic methods, this study was designed to evaluate the ability of surgeons to estimate elasticity by direct inspection and palpitation during intra-operative nodal staging of gastric cancer.

PATIENTS AND METHODS

Between 2008 and 2009, 57 consecutive patients with gastric cancer underwent curative gastrectomy and all their regional lymph nodes showing metastatic involvement were intra-operatively counted using direct inspection and palpitation by surgeons.

RESULTS

The overall sensitivity, specificity, and accuracy were 63.1%, 86.8%, and 82.8%, respectively. The sensitivity was higher in D1 lymph nodes such as No.6, No.5, No.7, and No.3. The specificity and accuracy were higher in D2 lymph nodes such as No.9, No.11p and No.8a.

CONCLUSIONS

Nodal diagnosis through direct inspection and palpitation by surgeons could be a reliable and accurate method in gastric cancer, comparable to other recent modalities. These data imply that tissue elasticity could be applied as a new modality in the nodal diagnosis of gastric cancer.

[A case of pancreaticoduodenectomy after the placement of an expandable metallic stent]

This is a case report of a 75-year-old man who underwent pancreaticoduodenectomy and received a placement of an expandable metallic stent (EMS) for palliation of the biliary stricture following diagnosis as middle bile duct carcinoma. At a local hospital, abdominal computed tomography revealed multiple low-density lesions with peripheral enhancement in the liver. After being diagnosed as metastatic liver tumor with cholangiocarcinoma, an EMS was inserted for palliation of the biliary stricture on the basis of the diagnosis as unresectable carcinoma due to the metastatic lesion. One month after stenting, because of relieving the biliary obstruction, no hepatic tumors were detected in either lobe by computed tomography. Based on this finding, the lesions were diagnosed as inflammatory pseudotumor of the liver rather than as metastatic liver tumor. A pancreaticoduodenectomy was performed without removal of the EMS, and fortunately, we were able to divide the bile duct upstream of the EMS. However, insertion of a stent may increase the difficulty of operation in many cases.

[Operative problems during simultaneous laparoscopic surgery for gastric and colorectal cancer]

Recent technological advances in optical and surgical devices have resulted in laparoscopic surgery for gastric and colorectal cancer, gaining wider acceptance and becoming more common. Simultaneous laparoscopic surgery for gastric and colorectal cancer has many potential advantages, including a small incision, good cosmetic result, less postoperative pain, and less mobility. However, some problems have to be resolved. To clarify the anastomotic problem of combined abdominal minilaparotomy, we present here 2 typical cases of simultaneous laparoscopic surgery for gastric and colorectal cancer. Case 1: The anastomoses after laparoscopic right hemicolectomy and distal gastrectomy were easily performed by combined upper abdominal minilaparotomy. Case 2: The anastomosis after laparoscopic right hemicolectomy was easily performed by upper abdominal minilaparotomy. However, the ensuing esophago-jejuno anastomosis after laparoscopic total gastrectomy resulted in failure during combined upper abdominal minilaparotomy because the anastomotic angle was incomplete. In conclusion, the choice of abdominal mini-incision site is crucial during simultaneous laparoscopic surgery for gastric and colorectal cancer. Surgeons should not hesitate to perform an additional mini-incision or change other anastomotic procedures if the operation is difficult, requires a long time to complete, and is likely to cause intraoperative complications.

[Neoadjuvant chemoradiotherapy for locally advanced rectal cancer]

A total of 37 patients treated with chemoradiotherapy between 2008 and 2011 were analyzed. Radiotherapy was administered in fractions of 1.8 Gy/day for 25 days. S-1 was administered orally in a fixed daily dose of 80 mg/m2 on days 1-5, 8-12, 22-26, and 29-33. Irinotecan(CPT-11 80 mg/m2) was infused on days 1, 8, 22, and 29. Curative surgery was performed 6-8 weeks later. The clinical downstaging rate was 40%. During the median follow-up time of 664 days, 37 patients survived. Recurrence was found in 8 patients. Local recurrence (pelvic lymph node metastasis) was only observed in 1 patient. Grade 3-4 toxic effects, including interstitial pneumonia, occurred in 27% of the patients. Neoadjuvant chemoradiotherapy may result in excellent local control with acceptable morbidity. However, longer follow up is required to assess neoadjuvant chemoradiotherapy for locally advanced rectal cancers.

[Diagnostic problems in gastric cancer patients with sarcoidosis-case report and literature review]

Sarcoidosis is an idiopathic systemic disease with non-caseating granuloma that is reported to occur concomitantly with various malignant tumors. We report here a case of advanced gastric cancer with sarcoidosis, for which precise preoperative diagnosis was difficult. A 69-year-old woman was diagnosed with a far-advanced gastric cancer because multiple intra-abdominal and intra-thoracic lymph node swellings and a tumorous lesion in the spleen were detected by multidetector computed tomography and fluorodeoxyglucose positron emission tomography. However, these multiple changes might be derived from sarcoidosis, because the multiple lymph node swellings were nonspecific changes for gastric cancer. With appropriate informed consent, surgery was selected in order to accurately confirm the stage of progression. Consequently, these changes were shown to not be metastatic, and curative surgery was performed. In conclusion, careful examination and a reasonable treatment strategy are important for avoiding the risk of overdiagnosis in gastric cancer patients with sarcoidosis.

[A case of advanced colon cancer resected successfully after neoadjuvant chemotherapy]

This case concerns a 54-year-old male patient who had been identified as having a type 2 tumor in the cecum, which subsequent pathologic examination revealed to be an adenocarcinoma. The results of a computed tomography (CT) scan suggested that the tumor had directly invaded the right iliopsoas. Neoadjuvant chemotherapy was performed to avoid a non-curative resection. CT and positron-emission tomography(PET) findings after the 6th course of chemotherapy revealed a significant reduction in tumor size, at which point a right hemicolectomy with D3 nodal dissection was performed. The changes from neoadjuvant chemotherapy were judged to be Grade 1a. The patient was recurrence-free at his 14- months follow-up examination. Neoadjuvant chemotherapy with a drug that targets a specific molecule is a useful treatment for patients with an unresectable primary cancer.

Clinicopathologic features and risk factors for extrahepatic recurrences of hepatocellular carcinoma after curative resection

BACKGROUND

The aim of this study was to clarify the clinicopathologic features of hepatocellular carcinoma (HCC) patients with extrahepatic metastasis after the removal of primary HCC, and the risk factors of extrahepatic recurrence.

METHODS

Clinicopathologic data were available for 264 HCC patients who underwent an R0 resection for HCC. Twenty-six patients who developed extrahepatic recurrence during the follow-up period (EXT group) were compared with patients who remained free from recurrence for at least 5 years after resection (n = 46) (No R group) or had only intrahepatic recurrences (n = 193) (INT group). We also estimated the risk factors of extrahepatic recurrence and survival in these 26 patients.

RESULTS

There were significant differences in primary tumor size, patient's age, findings in the noncancerous portion, macroscopic type, ductal invasion, intrahepatic metastasis, hepatic involvement and curability of primary tumor, treatment for recurrent tumor, and prognosis between the EXT group and the other groups. Extrahepatic recurrence was significantly associated with six factors by univariate analyses: age, indocyanine green (ICG) 15-min retention rate, tumor size, hepatic involvement of primary tumor, type of hepatectomy, and TNM stage, of which tumor size was an independent risk factor. Resection of recurrent tumor was the only independent favorable factor for survival of patients with extrahepatic recurrence.

CONCLUSIONS

HCC patients with extrahepatic recurrence had advanced primary tumors and poor prognosis. HCC patients with primary tumors larger than 60 mm were predicted to develop extrahepatic recurrence. Resection of recurrent tumor can improve the prognosis of HCC patients with extrahepatic recurrence.

Total pancreatectomy for pancreatic carcinoma: evaluation of safety and efficacy

BACKGROUND/AIMS

To determine the safety and the efficacy of total pancreatectomy for the curative treatment of pancreatic carcinoma.

METHODOLOGY

Retrospective analysis was performed using 10 patients receiving total pancreatectomy.

RESULTS

The median duration of the operative procedure was 8.7 hours and the median estimated blood loss was 2,700mL. Seven patients developed postoperative complications, including infections in 5 cases. There was no death associated with the operative procedure itself. Median period of postoperative hospital stay was 55 days. Anastomotic ulcer was prevented by administration of proton- pump inhibitors. Blood glucose level was well controlled by subcutaneous injection of sliding scale insulin during the postoperative period and the dosage of insulin required was 0.45±0.13units/kg body weight/ day at the time of discharge. The mean HbA1c level at 3 months after the operation was 6.1%. Four patients needed medication with anti-diarrheal drugs.

CONCLUSIONS

Total pancreatectomy could be performed safely and postoperative daily performance was reasonable with effective medication. We suggest that total pancreatectomy should be considered for the treatment of pancreatic carcinoma when the patient status is appropriate for this procedure.

Case involving long-term survival after esophageal cancer with liver and lung metastases treated by multidisciplinary therapy: report of a case

A 57-year-old male with lower esophageal cancer underwent subtotal esophagectomy with lymphadenectomy. The histopathological diagnosis was poorly differentiated squamous cell carcinoma, pT2N1M0 pStageIIB. After one course of postoperative adjuvant chemotherapy involving low-dose CDDP/5FU, a PET-CT scan obtained 12 months after surgery revealed a solitary liver metastasis in the S2 area. The patient then underwent five courses of docetaxel chemotherapy (80 mg/body, tri-weekly), and a partial response was observed. We also performed radiofrequency ablation (RFA), after which a complete response was observed. Twenty months after surgery, we detected local liver recurrence in the same position and performed additional RFA. Twenty-four months after surgery, a solitary lung metastasis was detected in the left S2 area and the patient was administered five additional courses of docetaxel therapy. Subsequently, PET-CT revealed growth of lung and liver tumors without recurrence in other areas. Twenty-nine months after surgery, we partially excised metastatic liver and lung tumors, and no subsequent recurrence has since been detected. The prognoses of patients who suffer from esophageal cancer organ recurrence are known to be extremely poor, and optimal therapeutic strategies for treating these patients have not been established. This long-term survival case suggests that multidisciplinary therapy for the treatment of liver and lung recurrence after esophagectomy is effective.

Progression of remnant gastric cancer is associated with duration of follow-up following distal gastrectomy

AIM

To re-evaluate the recent clinicopathological features of remnant gastric cancer (RGC) and to develop desirable surveillance programs.

METHODS

Between 1997 and 2008, 1149 patients underwent gastrectomy for gastric cancer at the Department of Digestive Surgery, Kyoto Prefectural University of Medicine, Japan. Of these, 33 patients underwent gastrectomy with lymphadenectomy for RGC. Regarding the initial gastric disease, there were 19 patients with benign disease and 14 patients with gastric cancer. The hospital records of these patients were reviewed retrospectively.

RESULTS

Concerning the initial gastric disease, the RGC group following gastric cancer had a shorter interval [P < 0.05; gastric cancer vs benign disease: 12 (2-22) vs 30 (4-51) years] and were more frequently reconstructed by Billroth-I procedure than those following benign lesions (P < 0.001). Regarding reconstruction, RGC following Billroth-II reconstruction showed a longer interval between surgical procedures [P < 0.001; Billroth-II vs Billroth-I: 32 (5-51) vs 12 (2-36) years] and tumors were more frequently associated with benign disease (P < 0.001) than those following Billroth-I reconstruction. In tumor location of RGC, after Billroth-I reconstruction, RGC occurred more frequently near the suture line and remnant gastric wall. After Billroth-II reconstruction, RGC occurred more frequently at the anastomotic site. The duration of follow-up was significantly associated with the stage of RGC (P < 0.05). Patients diagnosed with early stage RGC such as stage I-II tended to have been followed up almost every second year.

CONCLUSION

Meticulous follow-up examination and early detection of RGC might lead to a better prognosis. Based on the initial gastric disease and the procedure of reconstruction, an appropriate follow-up interval and programs might enable early detection of RGC.

Spontaneous rupture of the esophagus with extensive bowel necrosis caused by nonocclusive mesenteric ischemia: report of a case

We report a case of spontaneous rupture of the esophagus accompanied by extensive bowel necrosis caused by nonocclusive mesenteric ischemia. The patient was treated successfully with prompt surgical intervention after an early diagnosis. A 61-year-old man was admitted to our hospital complaining of abdominal pain after drinking. On arrival, he was suffering shock. Thoracoabdominal computed tomography and esophagoscopy findings were highly suggestive of rupture of the esophagus above the esophagogastric junction and extensive bowel necrosis. Emergency laparotomy revealed extensive bowel necrosis from the jejunum to the transverse colon; thus, we resected the entire affected region and performed jejunostomy and transverse colostomy. After suturing the esophageal perforation directly, we performed intramediastinal packing of the omentum and inserted drains. The patient recovered well and was discharged from hospital on postoperative day 126. To the best of our knowledge, this is the first case report of spontaneous rupture of the esophagus with nonocclusive mesenteric ischemia.

PSK induces apoptosis through the inhibition of activated STAT3 in human esophageal carcinoma cells

PSK, a protein-bound polysaccharide, is widely used in Japan as an immunopotentiating biological response modifier for cancer patients. PSK exerts antitumor activities through stimulation of the host's immune response; however, few studies have addressed the direct actions of PSK on tumor cells. Recently, it has been found that STAT3 is aberrantly activated in various types of malignancies, and plays a crucial role in tumor cell proliferation and survival. In the present study, STAT3 was constitutively activated in KYSE170 and TE13 esophageal carcinoma cells, and PSK inhibited proliferation and induced apoptosis in these cells in a dose-dependent manner. Based on these findings, the relationship between STAT3 and apoptosis in these cells was investigated. Results showed that PSK inhibited the expression of activated STAT3 and stimulated the expression of pro-apoptotic Bax in a dose-dependent manner, without affecting the expression of anti-apoptotic Bcl-xL and Mcl-1. These results indicate that PSK may induce apoptosis in esophageal carcinoma cells by inhibiting the expression of activated STAT3.

Factors resulting in 5-year disease-free survival after resection of hepatocellular carcinoma

BACKGROUND/AIM

Hepatectomy without recurrence for more than five years may be considered as being a sufficient resection of primary hepatocellular carcinoma (HCC). The purpose of the present study was to clarify the predictive factors for sufficient resection for HCC patients.

PATIENTS AND METHODS

In our Department, 77 patients with HCC survived without recurrence for more than five years following hepatectomy (curative group) and 187 patients underwent hepatectomy but developed recurrence within five years (recurrence group). We compared the clinicopathology between these two groups and evaluated the favorable factors for HCC without recurrence using logistic regression analysis.

RESULTS

The curative group was associated with three independent factors by multivariate logistic regression analyses: tumor size, serum indocyanine green retention rate (ICG15) and anatomic wide hepatectomy (all p<0.05).

CONCLUSION

Sufficient resection is closely related to patient, tumor, and treatment factors. Anatomic wide hepatectomy for small (<29 mm) HCC in patients with sufficient liver function (ICG15 <16.5%) can achieve sufficient resection.

The directionality of lymphatic spreading as a prognostic factor in gastric cancer: uni- or multidirectional lymphatic metastases

BACKGROUND/AIMS

The most critical problem of the numerical lymph node staging system is difficulty in evaluating preoperative staging. We investigated the directionality of metastatic lymph nodes as an alternative prognostic indicator of gastric cancer.

METHODOLOGY

One hundred and seventy two patients who had undergone curative gastrectomy were examined. We divided the stations of lymph nodes into three zones according to the anatomical site. Then patients were classified into two groups according to the number of positive zones, unidirectional or multidirectional lymphatic spreading.

RESULTS

Seventy-five patients showed unidirectional lymphatic spreading, whereas 97 patients showed multidirectional. Logistic regression analysis showed that directionality correlated with the number of metastatic nodes. Directionality was found to be a significant prognostic factor on univariate analysis, but not on multivariate analysis.

CONCLUSIONS

The directionality could be a surrogate marker of total number of metastatic lymph nodes as a prognostic factor in patients with gastric cancer.

Nodal counts on MDCT as a surrogate marker for surgical curability in gastric cancer

BACKGROUND

Thin-slice multidetector row computed tomography (MDCT) has emerged as a promising diagnostic modality in various cancers. This study was designed to evaluate the utility of metastatic nodal counts on MDCT as a surrogate maker for surgical curability in gastric cancer.

METHODS

Between 2005 and 2007, a total of 92 patients with gastric cancer underwent preoperative MDCT at a slice thickness of 1.0 mm at our hospital. All regional lymph nodes showing metastatic involvement were preoperatively counted.

RESULTS

Although the total counts of metastatic lymph nodes on MDCT were significantly smaller than those found by histopathology (P = 0.00001), there was a significant correlation between nodal counts on MDCT and histopathology by Spearman's analysis [P < 0.0001, pathologic counts = 1.63x (counts on MDCT) + 2.5]. Nodal counts on MDCT of ≥4 were analyzed as putative pathologic nodal counts of ≥8 by the equation, and pathologic metastatic nodal counts of ≥8 were most significantly correlated with noncurative resection (P < 0.0001). According to the logistic regression analysis, nodal counts on MDCT of ≥4 were a significant independent variable for noncurative resection (P = 0.0052, odds ratio 26.68). Nodal counts on MDCT of ≥4 could distinguish noncurative patients from curative patients with 94.4% sensitivity and 71.6% specificity.

CONCLUSIONS

Nodal counts on MDCT could be a reliable surrogate maker for surgical curability of gastric cancer. This marker might enable us to select prospective candidates for additional or alternative treatments in gastric cancer.

Differences of the lymphatic distribution and surgical outcomes between remnant gastric cancers and primary proximal gastric cancers

BACKGROUND

Although remnant gastric cancer (RGC) following distal gastrectomy is located in the proximal stomach, little is known about the differences of the lymphatic distribution and surgical outcomes between RGC and primary proximal gastric cancer (PGC).

METHODS

Between 1997 and 2008, 1,149 patients underwent gastrectomy for gastric cancer. Of these, 33 (2.9%) RGC patients and 207 (18.5%) PGC patients were treated at our department. We reviewed their hospital records retrospectively.

RESULTS

Compared with the PGC patients, those with RGC had a slightly higher age at onset (p=0.09), higher incidence of undifferentiated cancer (p=0.06), higher incidence of vascular invasion (p=0.09), and higher incidence of T4 (p=0.07). Gastrectomy for RGC involved greater blood loss (p<0.005), longer surgical duration (p=0.01), combined resection, and high incidence of complications. However, the survival rate for RGC patients was similar to that for PGC patients (p=0.67). 2) Patients with RGC had a different pattern of lymph node metastasis compared with that in PGC. Particularly in advanced RGC with pT2-T4 tumors, RGC frequently demonstrated jejunal mesentery lymph node metastases (RGC vs. PGC, 35% vs. 0%) and splenic hilar lymph node metastases (RGC vs. PGC, 17% vs. 10%). The jejunal mesentery lymph node metastases were detected only following Billroth II reconstruction (Billroth I vs. Billroth II, 0% vs. 67%).

CONCLUSION

Although the clinical behaviors of the two gastric cancers were different, the survival rates were similar. The pattern of metastasis indicates that the jejunal mesentery and splenic hilar lymph nodes should be specifically targeted for en bloc resection during complete gastrectomy in RGC.

A case of a superficial carcinoma of the esophagus with isolated lymph node metastasis around the abdominal aorta

Superficial carcinoma of the esophagus with isolated para-aortic lymph node metastasis is quite rare. A 56-year-old female demonstrated a type 0-IIa+IIb lesion in the middle thoracic esophagus on endoscopic examination. Enhanced computed tomography and positron emission tomography demonstrated two swollen lymph nodes on the right side of the inferior vena cava, but did not demonstrate either a primary lesion or regional lymph node metastasis. A retroperitoneal videoscopic lymph node biopsy was thus performed, and the histopathological diagnosis was metastasis of squamous cell carcinoma. Induction chemotherapy was administered with cisplatin/5-FU, and followed by definitive chemoradiotherapy with cisplatin/5-FU plus 60 Gy radiation. The patient showed satisfactory responses in both the primary and metastatic lesions. This is the first case report describing superficial carcinoma of the esophagus with isolated lymph node metastasis around the abdominal aorta. A precise histological diagnosis of the lymph node is quite important in such cases, and an adequate curative effect can be expected.

Risk factors for postoperative respiratory complications following esophageal cancer resection

The development of surgical and postoperative management techniques has improved the treatment outcomes of esophageal cancer resection. However, respiratory morbidity is still the most frequent complication after esophagectomy. The objective of the present study was to identify risk factors for respiratory complications following resection for esophageal cancer. This study included 96 patients with esophageal cancer who had undergone esophagectomy with lymph node dissection. The patients were divided into 2 groups according to the presence (20 patients, 17 had pneumonia and 3 had acute respiratory distress syndrome) or absence (76 patients) of postoperative respiratory complications (PRC). The two groups were compared with respect to their preoperative clinical variables, such as age, body mass index, smoking history, serum albumin, serum C-reactive protein (CRP), number of lymphocytes, %VC, FEV1.0% and FEV1.0. Furthermore, multiple logistic regression analyses were used to estimate relative risk factors for respiratory complications. Results of the univariate analysis showed that smoking history (+/-, patients with PRC, 19/1 and without PRC, 53/23), serum CRP (≥1.0 mg/dl/<1.0 mg/dl, patients with PRC, 6/14 and without PRC, 6/70) and FEV1.0% (≥60%/<60%, patients with PRC, 16/4 and without PRC, 73/3) were significantly different between the two groups. Multiple logistic regression analysis showed that FEV1.0% was the strongest predictor of PRC. FEV1.0%, serum CRP and smoking history are reliable predictors of the risk of respiratory complications following esophageal cancer resection. For patients with these factors, perioperative management for the prevention of postoperative respiratory complications should be considered.

The decision criterion of histological mixed type in "T1/T2" gastric carcinoma--comparison between TNM classification and Japanese Classification of Gastric Cancer

BACKGROUND

This study was designed to evaluate the clinical significance of undifferentiated component in differentiated T1/T2 gastric adenocarcinoma.

METHODS

Two hundred thirty-one patients who underwent curative gastrectomy were diagnosed pathologically as differentiated type T1/T2 gastric cancer according to Japanese Classification of Gastric Carcinoma (JCGC). The patients were divided into subgroups, pure differentiated type (pure D group, 181 patients) and differentiated-predominant mixed type (D > U group, 51 patients). The clinicopathological features of D > U group were compared with those of pure D group, and also those of undifferentiated-predominant type (U > D group).

RESULTS

Patients in D > U group were more likely to have larger and deeper tumors with lymphatic invasion and metastases than pure D group. However, there was no significant difference in clinicopathological factors between D > U and U > D groups, except for depth of tumor invasion. The postoperative 5-year survival rate of D > U group was significantly poorer than that of pure D group (88% and 98%, P = 0.011). Multivariate analysis revealed the presence of undifferentiated component was an independent prognostic factor.

CONCLUSIONS

The presence of undifferentiated component in differentiated T1/T2 gastric cancer is associated with tumor progression. Therefore, the decision criterion of histological mixed type in TNM classification is better suited than JCGC in T1/T2 gastric cancer.

Intraoperative real-time cholangiography and C-tube drainage in donor hepatectomy reduce biliary tract complications

BACKGROUND

In living-donor liver transplantation, biliary tract complications are a serious problem for recipients and donors.

METHODS

We applied intraoperative real-time cholangiography using a C-arm and/or C-tube drainage to reduce biliary tract complications in donor hepatectomy. From 2003 to 2010, intraoperative real-time cholangiography and C-tube drainage was applied to 39 and 19 donor cases, respectively. Fifteen donor cases had both procedures.

RESULTS

We confirmed the division line of the hepatic duct by visualizing a stricture on the monitor of the C-arm by pulling a thread and dissecting the proper site of the bile duct. The number of hepatic ducts of the graft to be anastomosed was 1 in 11 cases and 2 or 3 in 8 of the 19 cases without intraoperative real-time cholangiography, and it was 1 in 32 cases and 2 in 7 of the 39 cases with intraoperative real-time cholangiography. Bile leakage from the resection occurred in seven donors without, and in none of those with, C-tube drainage.

CONCLUSION

In living-donor liver transplantation, intraoperative real-time cholangiography enables effective determination of the precise division line of the hepatic duct. Moreover, C-tube drainage is effective for reducing bile leakage from the resected surface of the liver of donors.

[A case with juvenile hepatocellular carcinoma without hepatitis underwent right hepatic Trisegmentectomy]

A 20-year-old man with juvenile hepatocellular carcinoma (HCC) without HBV, nor HCV infections. A complaint of pain in the right abdomen, wherein a bulky hepatic tumor occupying a large area of the right lobe as well as tumors that were 20 mm and 10 mm in size in liver regions S2 and S3, respectively, were observed via an abdominal CT scan. A biopsy resulted in a diagnosis of well-differentiated hepatocarcinoma. The main voluminous tumor mass in the right lobe was resected, but the tumor still remained in the lateral segment after the surgery. On day 21 after the surgery, we initiated a therapy for the remaining tumor. He is still alive 36 months after surgery.

[Novel treatment strategy using Trafermin® consisting of bFGF for intractable pancreatic fistula following gastrectomy for gastric cancer-a case report with literature reviews]

Despite recent perioperative technological advances in gastric cancer, intractable pancreatic fistula is still a major critical complication following gastrectomy and should be specifically targeted in the effort to improve postoperative outcomes. We preliminary report here a successfully treated case with intractable pancreatic fistula using Trafermin® consisting of basic fibroblast growth factor (bFGF). A 67-year-old man underwent laparoscopic proximal gastrectomy with radical lymphadenectomy for early proximal gastric cancer (pT1bN0M0). After surgery, pancreatic fistula was occurred. Pancreatic fistula persisted for three months despite of surgical and several conservative treatments. After obtaining informed consent, we started to inject 50 μg/day of Trafermin® through a drainage tube into the dehiscence of pancreas. Consequently, pancreatic fistula was successfully closed within three weeks. Our novel treatment technique is simple, rapid and not costly. If informed consent was obtained from patients with low risk of recurrences, this technique should be recommended as one of the treatment choices for intractable pancreatic fistula following curative gastrectomy for gastric cancer.

[A case of failed laparoscopic and endoscopic cooperative surgery (LECS) for gastrointestinal stromal tumor of the stomach]

Recently, laparoscopic and endoscopic cooperative surgery (LECS) for submucosal gastric tumor has been developed to avoid an excessive surgical resection of gastric wall, which causes a deformity of the stomach and reduced oral intake. We report here a case of failed LECS for gastric submucosal tumor, and discuss the cause of failure. An 89-year-old woman underwent LECS for an intraluminal type submucosal tumor involving the upper and posterior gastric wall. Specifically, two sites of the gastric wall were fixed with subumbilical and left latero-abdominal wall approaches and two trocars with balloons were introduced into the stomach. Endoscopic submucosal resection was performed circumferentially around the tumor. Then, we tried to lift the tumor using an Endo-loop®. However, the amount of lifting was not sufficient for a safe surgical resection because the surgical field was extremely narrow. Therefore, we converted LECS to open surgery. In conclusion, it is important to consider clinical factors such as body size, tumor size and tumor location when planning LECS. Particularly, the intraabdominal suturing technique instead of using a linear stapler is desirable for a tumor involving the posterior wall.

[A case report of cholangiectasis with cholangiocarcinoma]

This is a case report of cholangiectasis with cholangiocarcinoma in a 37-year-old female. Both computed tomography (CT) and endoscopic retrograde cholangio-pancreatography (ERCP) demonstrated gallstone, and intrahepatic bile duct dilatation with the stone. The diagnosis was intrahepatic cholangiectasis without common bile duct-dilatation. Hepatectomy of segment 3 with resection of the extrahepatic bile duct and reconstruction of the biliary tract was performed. Upon pathological examination, an early stage of cholangiocarcinoma was pointed out within the small range of common bile duct without dilatation or stone. Cholangiocarcinoma with cholangiectasis has been reported to be induced by counter flow of pancreas and intestinal juice because of the pancreaticobiliary maljunction. So we usually choose a diversion operation as our tactics to get rid of the counter flow of those digestive juices. Despite the above-mentioned tendency, this is a very rare case of carcinogenesis in common bile duct without dilatation.

[A case of residual metastatic lymph node lesion following definitive chemoradiotherapy for T4 esophageal cancer, successfully treated by outpatient clinic-based sequential chemotherapy with docetaxel followed by S-1]

Patients with T4 esophageal cancer generally have poor prognosis. Of these patients, prognosis of non-responder to chemoradiothrapy (CRT) is extremely poor. We report a case of residual lymph node metastasis following definitive CRT, which showed a good response to outpatient clinic-based chemotherapy consisting of docetaxel (DOC) followed by S-1 in a patient with T4 esophageal cancer. The patient was a 65-year-old man with the diagnosis of squamous cell carcinoma of the middle thoracic esophagus with the 5 cm size lymph node metastasis with tracheal invasion along right recurrent laryngeal nerve [T4 (106recR-rt subclavian A) N2M0, Stage IVa]. He underwent induction chemotherapy with two courses of FP followed by one course of DCF. As a result, primary tumor was judged as complete response on endoscopy, and the lymph node lesion was judged as partial response, but unresectable on CT. Then, he underwent definitive CRT (FP+60 Gy). Following CRT, although the lymph node lesion was judged as non-CR on CT, a significant decrease of FDG uptake (PET-CR) was observed on PET-CT. Five months later, a recurrence of the lymph node lesion was observed on PET-CT. Then, he underwent outpatient clinic-based chemotherapy with DOC( 60 mg/m², triweekly) followed by S-1( 80 mg/ body/day, 6 weeks/course, administration for 4 weeks with 2 weeks cessation). DOC was administered for 8 months, and was converted to S-1 because of the regrowth of the lesion on PET-CT. After 3 months following initiation of S-1, a remarkable decrease of the lesion was observed on PET-CT. During outpatient clinic observation, the residual lymph node lesion after definitive CRT was well controlled over 1 year, and no new metastatic lesions were observed at other sites. Sequential chemotherapy with DOC followed by S-1 may be effective in controlling progression of resistant tumor against prior CRT.

Use of multidetector-row computed tomography to evaluate branch duct type intraductal papillary mucinous neoplasms of the pancreas: influence on surgical decision-making

BACKGROUND/AIMS

The purpose of this study was to evaluate factors predictive of the malignant grade associated with branch duct type intraductal papillary mucinous neoplasm (BD-IPMN) using multidetectorrow computed tomography (MDCT).

METHODOLOGY

We reviewed the morphological features of 26 BDIPMNs using MDCT. Tumor size, caliber of the main pancreatic duct, number of mural nodules, diameter of the largest mural nodule and volume of the largest mural nodule were assessed and correlated with the pathological findings.

RESULTS

By multiple- and single-regression analyses and Mann-Whitney U test, significant differences in the caliber of the main pancreatic duct and number of mural nodules were observed between adenoma and non-invasive carcinoma and in the number of mural nodules between adenoma and invasive carcinoma. No significant differences were observed between non-invasive carcinoma and invasive carcinoma. Based on the differential diagnostic criterion of 1 or more mural nodules for distinguishing adenoma from non-invasive carcinoma and invasive carcinoma, the sensitivities were 60% and 100%, respectively, and the specificity was 93% for both.

CONCLUSIONS

Although it was impossible to distinguish non-invasive carcinoma from invasive carcinoma, MDCT was reliable for distinguishing adenoma from non-invasive carcinoma and invasive carcinoma.

Long-term survival of a patient with common bile duct cancer after Virchow's node recurrence: Report of a case

A 62-year-old male patient with common bile duct (CBD) cancer underwent pancreaticoduodenectomy with lymphadenectomy in 2002. Histological examinations revealed moderately differentiated tubular adenocarcinoma with lymph node metastasis around the pancreas head and hepatoduodenal ligament. No adjuvant chemotherapy was performed, due to the risk of side effects. Two years after the first operation, new lesions developed at the left supraclavicular area. These lesions were considered to be Virchow's node metastasis of the original CBD cancer. However, we could not detect any other metastatic lesions in the intraabdominal lymph nodes around the aorta. We resected the lesion. Histological examinations showed a similar histological appearance of this lesion to that of the CBD cancer resected in 2002. At present, the patient has survived for more than 80 months after receiving the second surgery. In selected cases, surgery might be considered even for a Virchow's node metastasis of CBD cancers if there are no other recurrent lesions.

Risk factors and management of postoperative bile leakage after hepatectomy without bilioenteric anastomosis

BACKGROUND/AIMS

Bile leakage frequently causes major complications after hepatic resection. We investigated perioperative risk factors and management of postoperative bile leakage after hepatic resection without extrahepatic biliary resection and reconstruction.

METHODS

We included 247 consecutive patients who underwent elective hepatic resection without bilioenteric anastomosis at our institution between 2002 and 2009. Perioperative risk factors, including patient and surgical variables, were evaluated using univariate and logistic regression analyses.

RESULTS

Postoperative bile leakage occurred in 26 patients (10.5%). The surgical drain was retained in 6 patients (23%); 9 (35%) underwent drain salvage and 11 (42%) underwent percutaneous puncture under computed tomography or ultrasound guidance. Eight patients underwent endoscopic nasobiliary drainage (ENBD) for postoperative bile leakage, and bile leakage healed at a median interval of 19.5 days after ENBD. By univariate analysis, postoperative bile leakage was associated with central bisectionectomy, surgical time and intraoperative blood loss. Logistic regression analysis identified central bisectionectomy as an independent risk factor for postoperative bile leakage (p = 0.0003, odds ratio 16.724).

CONCLUSION

Meticulous procedures are necessary during parenchymal hepatic resection, especially during central bisectionectomy. Drain management should be precise in the case of postoperative bile leakage. We believe ENBD may rapidly cure postoperative major bile leakage.

Clinical evaluation of JCGC and TNM staging on multidetector-row computed tomography in preoperative nodal staging of gastric cancer

BACKGROUND/AIMS

Multidetector row computed tomography (MDCT) has emerged as a new diagnostic technology in various cancers. The aim was to evaluate its clinical compatibility with the 13th Japanese Classification of Gastric Carcinoma (JCGC), the 6th TNM and the new 14th JCGC/ 7th TNM systems in preoperative nodal staging (N-stage) of gastric cancer.

METHODOLOGY

Between January 2005 and December 2007, 92 consecutive patients with gastric cancer underwent preoperative MDCT at a slice thickness of 1.0 mm.

RESULTS

The 13th JCGC N-stage on MDCT demonstrated the potential correlation with pathological findings (p=0.057). However, preoperative 6th TNM and the new 14th JCGC/7th TNM N-stage on MDCT from N1 to N3 did not significant correlate with pathological findings (p=0.979, 0.847) because the number of metastatic lymph nodes detected preoperatively on MDCT was significantly smaller than that detected on pathological diagnosis (p<0.0001).

CONCLUSIONS

Nodal staging in the 13th JCGC staging system correlates with histological examination better than the 6th TNM and 14th JCGC/7th TNM staging systems. The optimal preoperative nodal staging using the current 14th JCGC/7th TNM staging system on MDCT needs further investigation.

Long-term survivors of esophageal carcinoma with distant lymph node metastasis

BACKGROUND/AIMS

Clinical extra-regional lymph node metastasis, M1 lymph node metastasis (M1 LYM), has been recognized as a far advanced condition in esophageal cancer. However, some patients with M1 LYM survive long-term. The purpose of this study was to identify the clinicopathological features of those patients with M1 LYM achieving long-term survival.

METHODOLOGY

Between 2002 and 2008, 31 patients with squamous cell carcinoma of the thoracic esophagus with M1 LYM were treated at our institution. Of the 31 patients, four survived for more than three years. These four patients were examined retrospectively.

RESULTS

Cervical lymph node metastasis was the cause of M1 LYM and no regional nodal metastasis was detected in any of the four patients. Primary lesions were non-T4 and located at the middle or lower thoracic esophagus in these patients. Two patients underwent radical esophagectomy with three-field lymphadenectomy and complete resection was confirmed by pathological examination. The other two patients underwent definitive chemoradiotherapy and complete response was confirmed. Three patients are alive without recurrence but one, who underwent definitive CRT, died of local recurrence.

CONCLUSION

Solitary metastasis localized at the cervical node might be targeted specifically in an effort to improve the prognosis of M1 LYM patients with esophageal cancer.

Expression of cancer stem cell markers CD133 and CD44 in locoregional recurrence of rectal cancer

BACKGROUND

Recent findings suggest that cells with surface CD markers include cancer stem cells (CSCs) which can produce a cancer cluster, and that the presence of CSCs may be linked with prognosis. CD133 and CD44 are among the most useful markers for identification of colorectal CSCs.

MATERIALS AND METHODS

An immunohistological analysis of CD133 and CD44 was performed using tissue from cases shown to be locoregionally recurrent or non-recurrent clinico-pathologically.

RESULTS

The CD133-positive rates were 38.7% and 59.23% in non-recurrent and recurrent cases, respectively, and the CD44-positive rates were 35.5% and 44.4%, respectively. Expression of the CD markers had no correlation with other clinicopathological factors. The prognosis of patients who were positive for both markers was significantly worse than that of other patients.

CONCLUSION

These results suggest that detection of CD133 and CD44 can provide useful information for selection of treatment and performance of intensive follow-up of colorectal cancer.