Endoscopic Surgical Skill Qualification System: propensity-score matched cohort analysis of accredited supervisors in laparoscopic rectal cancer surgery

BACKGROUND

The Endoscopic Surgical Skill Qualification System (ESSQS) in Japan evaluates the surgical skills required for laparoscopic surgery as an operator as well as a supervisor. This study aimed to demonstrate the benefits of an ESSQS-certified surgeon's participation in laparoscopic rectal resections as a supervisor (assistant or advisor).

METHODS

We retrospectively reviewed laparoscopic resection results for cStage II and III rectal cancer performed at 56 Japanese hospitals between 2014 and 2016. We used propensity score matching to generate paired cohorts with or without an ESSQS-certified supervisor at a one-to-one ratio. The impact of ESSQS-certified supervisors' participation on short-term outcomes was assessed. In the matched cohort, multivariable logistic regression analysis and multivariable regression analysis of postoperative complication rate and intraoperative blood loss were performed to further mitigate the impact of pathological factors.

RESULTS

Two groups (n = 399 each) with or without an ESSQS-certified supervisor were well matched by clinical factors. The group with an ESSQS-certified supervisor had lower blood loss (68 mL vs. 98 mL, P = 0.036) and a lower incidence of severe morbidities of Clavien-Dindo grade ≥IIIa (8.0% vs. 13.3%, P = 0.016). Multivariable logistic regression analysis and multivariable regression analysis confirmed that the attendance of ESSQS-certified supervisors reduced postoperative complication occurrence (adjusted odds ratio: 2.28, 95% confidence interval: 1.38 - 3.80, P = 0.001) and intraoperative blood loss (estimated difference: -15.7 mL, P = 0.016).

CONCLUSION

This study demonstrated the educational benefits of ESSQS-certified supervisors, including assistants and advisors, evidenced by their superior short-term outcomes.

[Long-Term Survival of a Patient with Hepatocellular Carcinoma after Surgical Resection of Metachronous Hilar Lymph Node Metastases]

The recurrence of hepatocellular carcinoma(HCC)is primarily due to intrahepatic metastases. Additionally, extrahepatic HCC metastases most commonly occurs in the lungs, lymph nodes, adrenal glands, and bones. Systemic chemotherapy is the standard treatment for extrahepatic metastases. Although several reports on surgical resection of lymph node metastases (LNM) in patients with HCC have been published, its clinical benefits remain controversial. We report a case in which surgical resection of LNM was performed in a patient with HCC. The patient was a 74-year-old woman diagnosed with HCC and non-B non-C chronic hepatitis, for which she underwent a laparoscopic partial hepatectomy. The pathological diagnosis was St-A, 1.6×1.4 cm, confluent multinodular type, pT1N0M0, fStage Ⅰ. Nine months later, 2 LNM on the liver hilum were detected and managed with sorafenib. Sorafenib was discontinued after 2 months due to the development of Grade 3 hand-foot syndrome. Since no new lesions were detected on follow-up, lymph node resection was performed. The patient remains disease-free 4.5 years postoperatively.

A case of intraductal papillary neoplasm of the bile duct accompanied by intraductal papillary mucinous neoplasm of the pancreas and hepatocellular carcinoma

A 73-year-old man with mixed-type intraductal papillary mucinous neoplasm of the pancreas body was followed up for 14 years. Based on imaging findings, the intraductal papillary mucinous neoplasm of the pancreas met the high-risk stigmata, and new hepatic masses were suspected to be intraductal papillary neoplasms of the bile duct. With a diagnosis of intraductal papillary mucinous neoplasm of the pancreas and intraductal papillary neoplasm of the bile duct, the patient had undergone left lateral hepatectomy and distal pancreatectomy. Based on pathology, the pancreatic specimen was diagnosed as a high-grade intraductal papillary mucinous neoplasm of the pancreas, and the hepatic specimen was diagnosed as an intraductal papillary neoplasm of the bile duct and hepatocellular carcinoma. The intraductal papillary neoplasms of the bile duct and hepatocellular carcinoma were adjacent to each other. Fifteen months after surgery, recurrence in the remnant pancreas was detected. The patient had undergone residual total pancreatectomy, with no recurrence thirty months after the second resection. This case demonstrates that second surgery for metachronous high-risk lesions in the remnant pancreas of patients with intraductal papillary mucinous neoplasm of the pancreas and intraductal papillary neoplasm of the bile duct may also be considered to improve survival.

Hepatocellular carcinoma recurrence in the extrahepatic bile duct wall: A case report

We should know that hepatocellular carcinoma can progress as if it replaces the bile duct wall itself.

[A Case of Complete Resection Using the Liver-First Approach after Systemic Chemotherapy in a Patient with Synchronous Colorectal Liver and Lung Metastases]

Conversion surgery for patients with initially unresectable colorectal liver metastases is increasingly being performed because of effective systemic chemotherapy. Additionally, many studies have reported the benefit of the liver-first approach for advanced liver metastasis. We report a case of an initially unresectable advanced colon cancer with multiple liver and lung metastases that was successfully treated with the liver-first approach following chemotherapy. The patient was a 36-year- old woman who was diagnosed with advanced rectal cancer, cT4aN2aM1b, cStage Ⅳb. After a temporary transverse colostomy, she was administered systemic chemotherapy for 9 months. The primary tumor and liver metastases showed partial response while the lung metastases showed complete response. Since it was considered that liver metastases were the main prognostic factors, we performed a right hemihepatectomy plus S3 partial hepatectomy, followed by laparoscopic high anterior resection. A partial pneumonectomy was also performed because of the regrowth of the lung metastases, and we succeeded in complete resection. The liver-first approach was a beneficial treatment option for this patient with unresectable colorectal liver metastases.

A case of laparoscopic anterior resection for rectal cancer with duplication of the inferior vena cava using preoperative 3D computed tomography angiography

We report the case of a patient with duplication of the inferior vena cava (DIVC) who underwent anterior laparoscopic resection for rectal cancer. A 66-year-old woman presented with abnormal lung shadows on a chest x-ray during a routine health checkup. She was diagnosed with rectal cancer and lung metastasis using colonoscopy and thoracoabdominal computed tomography (CT). In addition, a 3D CT angiography revealed double inferior vena cava, one on either side of the aorta. The preoperative diagnosis was rectal cancer cT3N0M1a(Lung) cStage IVA with DIVC, and a two-stage surgery was planned. The first stage was high anterior laparoscopic resection. This was safely performed because the pre-hypogastric nerve fascia was preserved and the left inferior vena cava was not visualized during the surgery. During the second stage of the surgery, video-assisted thoracoscopic left lower lobectomy was performed and no recurrence was observed for >6 months after the second surgery.

[Adenocarcinoma in the Lung Detected Due to the Development of Perforative Peritonitis Caused by Small Intestinal Metastasis-A Case Report]

Previous studies have reported that perforations of the small intestine caused by metastatic tumors prior to the diagnosis of primary lung cancer are very rare. A 79-year-old man was admitted to our hospital with acute lower abdominal pain. Abdominal computed tomography revealed intraperitoneal free air around the bowel wall thickening in the small intestine. The patient was diagnosed with acute peritonitis caused by perforation of the small intestine, and an emergency operation was performed. Laparotomy revealed perforation in the jejunum without any palpable tumor in the abdomen. Partial resection of the jejunum revealed an ulcerating lesion at the perforation site. Histological examination indicated small intestinal metastasis secondary to lung adenocarcinoma. Positron emission tomography performed after discharge showed a small reticular opacity with intense accumulation of FDG in the left lung. The patient was diagnosed with perforation of the small intestine metastasis secondary to lung adenocarcinoma. The postoperative course was uneventful; the patient received chemotherapy, and is alive 6months after the operation.

[A Case of Trousseau Syndrome Complication during Chemotherapy for Advanced Gastric Cancer]

The pathological condition which causes cerebrovascular disease through hypercoagulability associated with malignant tumors is known as Trousseau syndrome. Here, we report the case of a patient with Trousseau syndrome which developed as a complication during chemotherapy for advanced gastric cancer. A 70-year-old woman with multiple lymph node metastases of gastric cancer underwent TS-1 plus CDDP chemotherapy before surgery. She had symptoms of left hemiparesis during the first course of chemotherapy. She was diagnosed with acute cerebralinfarction using brain MRI, and blood tests indicated hypercoagulability. Therefore, it was strongly suspected that she had Trousseau syndrome. A total of 2 courses of chemotherapy were administered, along with anticoagulation therapy with edoxaban. She exhibited improved paralysis and received a totalgastrectomy after chemotherapy. According to recent reports, more than 90% of patients with malignant tumors have hypercoagulability, and more than 50% of them have thromboembolisms. It is therefore essential to obtain early diagnosis and provide anticoagulation therapy for cerebral infarction, and to provide treatment against malignant diseases in patients with Trousseau syndrome.

Laparoscopic anatomical segment 3 segmentectomy for hepatocellular carcinoma accompanied by hypoplasia of the right hepatic lobe

We report a case of laparoscopic anatomical segment 3 segmentectomy for hepatocellular carcinoma (HCC) accompanied by hypoplasia of the right hepatic lobe. An 80-year-old man was admitted with a suspicion of HCC diagnosed by computed tomography during follow-up for thyroid cancer. Dynamic computed tomography showed 40-mm HCC in segment 3 and hypoplasia of the right hepatic lobe with the Chilaiditi sign. We performed laparoscopic anatomical segment 3 segmentectomy. There were no postoperative complications, and the patient was discharged 6 days postoperatively. This procedure can be performed safely and is technically feasible, but special attention should be paid to anatomical alterations to avoid fatal surgical complications.

[A Case That Was Complicated with Pulmonary Artery Thrombosis during Chemotherapy of the Regimen of CapeOX plus Bevacizumab against Recurrence of Colon Cancer]

An 80-year-old woman with peritoneal dissemination after laparoscopic right hemicolectomy for appendicular carcinoma (mucinous adenocarcinoma, pT4aN1M0, stage Ⅲa)underwent CapeOX plus bevacizumab chemotherapy. The patient achieved stable disease over 5 courses of the treatment. Subjective and objective symptoms were not observed; however, chest computed tomography findings revealed a thrombus in the pulmonary artery that was considered to be associated with bevacizumab. Chemotherapy was discontinued, and anticoagulation therapy was initiated with heparin and then switched to apixaban. The thrombus resolved with treatment, but the patient died following an increase in peritoneal dissemination. CapeOX plus bevacizumab is a recommended colon cancer treatment, and even though it is generally considered safe, the side effects of bevacizumab include relatively rare occurrences of gastrointestinal perforation or thrombosis. The frequency of pulmonary embolism associated with bevacizumab is approximately 0.1%, and fatalities have been reported. The possibility of asymptomatic thrombosis warrants regular monitoring of this serious side effect in patients receiving bevacizumab. Early detection and prompt antithrombotic treatment are necessary to ensure patient safety and continued disease management.

Oncological outcomes of robotic-assisted laparoscopic versus open lateral lymph node dissection for locally advanced low rectal cancer

BACKGROUND

The long-term outcomes of robotic-assisted laparoscopic lateral lymph node dissection (RALLD) have not been fully investigated. This study aimed to assess the oncological and long-term outcomes of RALLD for rectal cancer through comparison with those of open lateral lymph node dissection (OLLD) in a retrospective study.

METHODS

Between September 2002 and October 2014, the medical data of 426 patients who underwent total mesorectal excision with lateral lymph node dissection for primary rectal cancer were collected. Of these, 115 patients were excluded after data collection (stage IV, n = 61; total pelvic exenteration, n = 31; multiple cancer, n = 20; conventional laparoscopic surgery, n = 3). Before matching, 311 patients with clinical stage II/III were analyzed. Using exact matching, patients were stratified into RALLD (n = 78) and OLLD (n = 78) groups. Pathological findings and long-term outcomes were compared between the groups.

RESULTS

The pathological stage and number of harvested lymph nodes showed no significant differences between the groups. The rate of positive resection margin in the RALLD group tended to be lower compared with that of the OLLD group (p = 0.059). The median follow-up duration was 54.0 months in 156 patients. The 5-year overall survival rate was 95.4 and 87.8% in the RALLD and OLLD groups, respectively (p = 0.106). The 5-year relapse-free survival rate was 79.1 and 69.9% in the RALLD and OLLD groups, respectively (p = 0.157). The 5-year local relapse-free survival rate was 98.6 and 90.9% in the RALLD and OLLD groups, respectively (p = 0.029).

CONCLUSIONS

The short- and long-term outcomes indicated that RALLD may be a useful modality for locally advanced low rectal cancer.

Prognostic factors in patients who received surgery for colorectal cancer with peritoneal metastasis

574

Background: Peritoneal metastasis (PM) in patients diagnosed with colon cancer is associated with a poor prognosis. We aimed to analyze prognostic factors associated with PM in patients diagnosed with colorectal cancer (CRC). Methods: We evaluated 237 patients who underwent surgery between 2002 and 2016 for CRC with PM. The extent of PM was evaluated using the Peritoneal Cancer Index (PCI). Clinicopathological variables, PCI score, surgical curability, and the administration of postoperative chemotherapy were evaluated. Overall survival was analyzed using the Kaplan-Meier method. Multivariate analysis was performed to assess the prognostic value of these variables, using the Cox regression model. Results: Our patients included 119 men and 118 women with a median age of 64 (range: 21–90) years. The primary tumor sites were the right-sided colon (n = 103), left-sided colon (n = 84), and rectum (n = 50). The median PCI score was 4 (range: 1–30). Synchronous PM was detected at the time of diagnosis of the primary tumor in 165 patients (69.6%). Distant metastases except peritoneal metastases was detected in 137 patients (57.8%). R0 resection was performed in 62 patients (19.0%). Postoperative chemotherapy was performed in 165 patients (69.6%). The median survival time in all patients was 19.4 (range: 0–30) months, and the five-year overall survival rate was 16.3%. Multivariate analysis revealed that PCI ≤ 5 (hazard ratio [HR]: 2.56, 95% confidence interval [CI]: 1.56-4.32, P < 0.01); the absence of distant metastasis, except peritoneal metastasis (HR: 1.65, CI: 1.15-2.40, P < 0.01); R0 resection (HR: 4.21, CI: 2.44-7.50, P < 0.01) affected the survival rate. Conclusions: Our results show that a low PCI, the absence of distant metastasis except peritoneal metastasis, and R0 resection are prognostic factors in patients diagnosed with PM-CRC.

Effect and safety of proton beam therapy for locally recurrent rectal cancer

743

Background: The first choice of treatment for locally recurrent rectal cancer is surgical resection. However, the operation is often difficult with high perioperative risk. For surgically unfit cases, proton beam therapy (PBT) is proposed as the treatment option. However, its efficacy for locally recurrent rectal cancer remains unclear. Therefore, this study aimed to evaluate the efficacy and safety of PBT for locally recurrent rectal cancer. Methods: A total of 23 patients with locally recurrent rectal cancer who received PBT were retrospectively evaluated, from November 2005 to July 2014. Patients with single lesion, who refuse the radical surgical therapy, or who were considered unfit for the operation were included in this study. All patients were treated with 2.8Gy relative biological effectiveness (RBE)/fraction. Twenty-five irradiations were performed, with a total irradiation of 70Gy RBE. Unfit for operation criteria include invasion to the vertebra higher than the third sacrum or lateral lymph node recurrence after a lateral lymph node dissection. To assess the safety of PBT, adverse events were evaluated by using the Common Terminology Criteria for Adverse Effects (CTCAE version4.0). To assess the efficacy, the overall and relapse-free survival rates and local control rate were evaluated. Results: Sixteen patients were unfit for operation, and seven refused surgery. Three patients experienced Grade 3 late adverse events in the CTCAE (two ileum fistula and one urinary tract obstruction). The median follow-up time was 28.9 months. The 5-year overall and relapse-free survival rates were 47.6% and 20.2%, respectively. Fifteen patients (65.2%) showed distant metastasis or regrowth at the locally recurrent site. The 5-year local control rate was 39.0%. Ten patients (43.4%) showed regrowth at the proton beam irradiation site. Conclusions: PBT was relatively effective for locally recurrent rectal cancer with manageable adverse effects. Therefore, PBT may be considered as the therapeutic option for selected locally recurrent rectal cancer patients.

Robotic surgery for rectal cancer: Short-term and oncological outcomes for 607 consecutive patients

756

Background: Conventional laparoscopic surgery (CLS) for rectal cancer has several inherent technical difficulties, including a limited range of motion of the instruments.Robot-assisted laparoscopic surgery (RALS) has some technical advantages over CLS because it improves dexterity with an increased range of movements at the tips of the instruments. The purpose of this study was to evaluate the short-term and oncological outcomes of RALS for rectal cancer, including robotic, autonomic nerve-preserving, lateral lymph node dissection (RALLD), a new, technically challenging procedure. Methods: Between December 2011 and August 2017, 607 consecutive patients underwent RALS for rectal cancer. Surgical outcomes, pathological results, and oncological results were investigated retrospectively. Results: There were 403 males and 204 females; 577 patients had adenocarcinoma, 19 had carcinoid tumor, 8 had GIST, and 2 had other malignant tumor. The types of procedures performed were: 453 anterior resections, 93 intersphincteric resections, and 61 abdominoperineal resections. RALLD was performed in 202 patients (33.3%). Preoperative chemoradiotherapy was performed in 34 patients. The overall median operative time was 257(109-683) min. In cases without RALLD, the median operative time was 217 (109-545) min, while median operative time was 420 (162-683) min with RALLD. None of the cases was converted to an open or laparoscopic procedure.There was no surgical mortality. The overall complication rate for Clavien-Dindo classification grade III-IV was 3.0%. The oncological results for 279 patients with primary rectal adenocarcinoma, operated before December 2014 was also investigated (Stage I/II/III 115/48/116). The 5-year overall survival was 96.6%, the 3-year relapse free survival was 88.3%, and 3-year local relapse free survival was 98.5%. The 3-year RFS of pStage I/II/III was 96.2/89.6/79.6% respectively. Conclusions: RALS for rectal cancer is a feasible procedure with low morbidity and a low conversion rate, and acceptable oncological results.

[A Case Report of Robotic Assisted Laparoscopic Low Anterior Resection in a Patient with Rectal Cancer and Polysplenia Syndrome]

Polysplenia syndrome is a rare congenital disease characterized by variable thoracic and abdominal anomalies. A man in his 70s was diagnosed with rectal cancer by close exploration for fecal occult blood. A barium enema revealed a type 1 rectal tumor andwith non-rotation of intestine. CT revealed multiple abnormalities: a polyspleen, preduodenal portal vein, congenital absence of the pancreatic tail, bilateral superior vena cava, andbilateral bilobedlung. Basedon these findings, the patient was diagnosedas having rectal cancer with polysplenia syndrome andtreatedwith robotic assistedlaparoscopic low anterior resection. At operation, the whole colon was located in the left side of the abdominal cavity. The whole colon adhered with each other. The ileocecum adheredto the front of the aorta andthe right iliac artery. In the pelvis, anatomical abnormality was not detectedandrectal mobilization andresection was performedas usual. The patient hadno signs of recurrence of the rectal cancer. This is the first case presentation of laparoscopic low anterior resection in a patient with rectal cancer and polysplenia syndrome.

Robotic-assisted multivisceral resection for rectal cancer: short-term outcomes at a single center

BACKGROUND

The safety and feasibility of robotic-assisted multivisceral resection for locally advanced rectal cancer remain unclear. The aim of this study was to assess the short-term outcomes of this procedure at our institution.

METHODS

From December 2011 to December 2016, patients who underwent robotic-assisted multivisceral resection for rectal cancer were investigated. Patient demographics, treatment characteristics, perioperative outcomes, and pathological results were evaluated retrospectively.

RESULTS

There were 31 patients; 17 men (54.8%) and 14 women (45.2%), with a median age of 65 years (range 40-82 years). Twenty-one patients (67.7%) had a cT4 tumor, 9 patients (29.0%) had a pT4b tumor, and all patients except one (96.8%) underwent complete resection of the primary tumor with negative resection margins. Eleven patients (35.5%) received neoadjuvant chemoradiation. The most commonly resected organ was the vaginal wall (n = 12, 38.7%), followed by the prostate (n = 10, 32.3%). Lateral lymph node dissection was performed in 20 patients (64.5%). The median operative time was 394 min (range 189-549 min), and the median blood loss was 41 mL (range 0-502 mL). None of the patients received intraoperative blood transfusions or required conversion to open. Overall, postoperative complications occurred in 11 patients (35.5%). The most frequent complication was urinary retention (n = 5, 16.1%), and none of the patients developed serious complications classified as Clavien-Dindo grades III-V.

CONCLUSIONS

Robotic-assisted multivisceral resection for rectal cancer is safe and technically feasible.

Is it important to palpate lymph nodes in open surgery for colorectal cancer?

INTRODUCTION

In laparoscopic or robotic surgery, surgeons cannot directly palpate lymph nodes (LN), which could be considered a shortcoming in that procedure. This study was performed to evaluate the importance of palpation diagnosis of LN metastasis in colorectal cancer surgery.

METHODS

This study enrolled 408 patients who underwent curative resection for primary colorectal cancer in our department in 2014. The diameter of each manually dissected LN was measured, and the LN was then examined by palpation to determine whether it was metastatic based on its consistency. The palpation and pathological diagnoses of each LN were compared. Sensitivities, specificities, positive predictive values, negative predictive values, and accuracies were calculated for palpation diagnosis of LN metastasis in a node-by-node analysis, according to LN size.

RESULTS

Of the 13 750 dissected LN, 444 LN (3.2%) were metastatic. Overall, palpation diagnosis of LN metastasis revealed node-by-node sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 50%, 98%, 52%, 98%, and 97%, respectively. The sensitivity for LN 3 mm and smaller and for LN 15 mm and larger was 3% and 90%, respectively.

CONCLUSION

Palpation diagnosis of LN metastasis in colorectal cancer surgery was unreliable. Although poor haptics is considered to be a disadvantage in laparoscopic and robotic surgery, they are not inferior to open surgery in terms of LN dissection.

A case of small intestinal endometrioid adenocarcinoma

Endometriosis generally occurs in the ovary. Intestinal endometriosis is rare. About 1 % of all endometriosis cases become malignant. Malignant transformation of small intestinal endometriosis is very rare. A 55-year-old woman who underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy and omentectomy for endometriosis 7 years ago presented to her primary care doctor with melena. A tumor was detected in the right lower abdomen by ultrasonography. The doctor referred her to our hospital. Computed tomography demonstrated a lobulated tumor ventral to the right common iliac vessels. Magnetic resonance imaging demonstrated that the tumor had heterogeneous intensity on T2-weighted images. Several small cysts with high intensity were observed caudal to the tumor on T2-weighted images. We performed partial small intestinal resection for the lesion. The tumor was diagnosed as endometrioid adenocarcinoma of the small intestine. She has been relapse-free for 5 years after surgery. Only three cases of malignant transformation of small intestinal endometriosis have been reported previously. It is very rare for long-term survival to be obtained with surgery alone, as in our case. This case report highlights the imaging findings for malignant transformation of intestinal endometriosis.

Relationship between stoma creation route for end colostomy and parastomal hernia development after laparoscopic surgery

BACKGROUND

The therapeutic benefits of extraperitoneal colostomy with laparoscopic surgery remain unclear. The aim of this study was to investigate the relationship between the route for stoma creation with laparoscopic surgery and stoma-related complications, especially parastomal hernia (PSH).

METHODS

From January 2007 to March 2015, a total of 59 patients who underwent laparoscopic abdominoperineal resection or Hartmann procedure were investigated. Patient demographic and treatment characteristics, including stoma-related complications, were analyzed retrospectively.

RESULTS

Transperitoneal and extraperitoneal colostomy were performed in 29 and 30 patients, respectively. Median follow-up duration was 21 months (range: 2-95). Patient demographic and treatment characteristics were comparable between the transperitoneal group (TPG) and the extraperitoneal group (EPG). PSH developed in 12 (41 %) patients in TPG, and 4 (13 %) patients in EPG (p = 0.020). The incidence of other stoma-related complications and non-stoma-related complications did not differ significantly between TPG and EPG. No patient characteristics except for transperitoneal route for stoma creation were associated with PSH development.

CONCLUSIONS

The extraperitoneal route for stoma creation is associated with a significantly lower incidence of PSH development after laparoscopic surgery. Whenever possible, extraperitoneal colostomy should be recommended, even with laparoscopic surgery.

ERRATUM

Histone deacetylase (HDAC) inhibitors have been shown to enhance the effects of 5-fluorouracil (5-FU) against various cancer cells; however, no report has shown that an HDAC inhibitor may enhance the effects of 5-FU with radiation. Therefore, we investigated whether the novel HDAC inhibitor OBP-801/YM753 could enhance the effects of 5-FU with radiation on esophageal squamous carcinoma KYSE170 cells. The inhibition of the cell growth was significantly stronger with the combination of OBP-801/YM753 with 5-FU than with the 5-FU treatment only. Furthermore, inhibition of the colony formation was the most effective with the combined treatment of OBP-801/YM753, 5-FU, and radiation. Western blot analysis showed that OBP-801/YM753 suppressed the expression of thymidylate synthase induced by 5-FU. Therefore, this three-combined therapy is promising for patients with esophageal squamous carcinoma.

Retrocardiac lung hernia after thoracic esophagectomy: report of a rare case

A retrocardiac lung hernia is an extremely rare complication after esophagectomy. A 56-year-old man was admitted to our hospital with advanced middle thoracic esophageal cancer and a giant bulla at the apical portion of the right lung. Since it appeared that dissection of the upper mediastinum would most likely require resection of the right bulla, a two-stage operation for esophageal cancer was planned. During the first-stage operation, thoracic esophagectomy and resection of the right giant bulla were performed. Fourteen days after the first-stage operation, the patient underwent laparotomy as the second-stage operation to reconstruct a narrow gastric tube via a retrosternal route. After the second-stage operation, the inflammatory reaction was prolonged. Therefore, a thoracoabdominal computed tomography scan was performed, showing retrocardiac pulmonary atelectasis. The patient was diagnosed with a retrocardiac left lung hernia in which the left lower lobe was displaced into the right thoracic cavity. Because the inflammatory reaction was due to effects of the lung hernia, a repair operation was performed via a left seventh intercostal thoracotomy. At thoracotomy, the left basal segment of the lung was atelectatic and reddish and had herniated into the right thoracic cavity through an opening between the aorta and pericardium. The herniated lung tip adhered strongly to the subcarina, and synechiotomy was performed. We believe that simultaneous removal of the right giant bulla with esophagectomy was the important cause of this complication.

Prognostic impact of tumor IL-6 expression after preoperative chemoradiotherapy in patients with advanced esophageal squamous cell carcinoma

Elevated serum interleukin-6 (IL-6) levels have been associated with tumor progression and poor prognosis in patients with esophageal carcinoma. The purpose of the present study was to clarify such a relationship in patients with esophageal squamous cell carcinoma with a focus on the possible influence of chemoradiotherapy (CRT) on tumor IL-6 expression. Data regarding 41 patients with clinical T3-T4 tumors who underwent induction chemoradiotherapy followed by surgery (CRT group) and 60 patients with clinical T1-T4 tumors who underwent surgery alone (Surgery group) between 2001 and 2010, were retrospectively analyzed. Tumor IL-6 expression in resected specimens was evaluated by immunohistochemistry. Tumor IL-6 expression was detected in patients with advanced tumors in the Surgery group (21.1% in p(stage) III-IV vs. 0.2% in p(stage) I-II; 27.8% in pT3-4 vs. 0% in pT1-2), and also correlated with primary tumor progression and surgical curability in the Surgery group. In addition, patients with IL-6-positive tumors had significantly shorter overall survival than those with IL-6-negative tumors in the CRT group, and tumor IL-6 expression had an independent prognostic value in multivariate analysis, whereas no significant difference in overall survival was observed between patients with IL-6-positive and those with IL-6-negative tumors in the Surgery group. These results indicate that pre-treatment tumor IL-6 expression correlates with primary tumor progression, and CRT-induced tumor IL-6 expression predicts poor prognosis.

Overexpression of IL-6 by gene transfer stimulates IL-8-mediated invasiveness of KYSE170 esophageal carcinoma cells

Interleukin-6 (IL-6) has been associated with disease progression and poor prognosis in esophageal carcinoma. The aim of this study was to investigate the possible influence of IL-6 on the biological activities of esophageal carcinoma cells in terms of invasiveness. The human esophageal carcinoma cell line, KYSE170, was transfected with a plasmid vector expressing IL-6, and a stable transfectant overexpressing IL-6 was established. Invasiveness was evaluated by an invasion assay and compared between IL-6 and control transfectants. The invasiveness of the IL-6 transfectant was significantly higher than that of the control transfectant, and was significantly reduced by IL-6-specific siRNA. In reverse transcriptase-polymerase chain reaction (RT-PCR) analysis, IL-8 expression was significantly higher in the IL-6 transfectant than in the control transfectant, whereas the expression of Hepatocyte growth factor (HGF) and Vascular endothelial growth factor (VEGF) was not different. IL-8 expression in the IL-6 transfectant was significantly inhibited by IL-8-specific siRNA, whereas IL-6 expression was not. In addition, the invasiveness of the IL-6 transfectant was significantly reduced by IL-8-specific siRNA. These results indicate that the overexpression of IL-6 increases the invasiveness of KYSE170 esophageal carcinoma cells and IL-6-induced IL-8 plays a predominant role in increasing invasiveness.

Time course of serum C-reactive protein levels during induction chemoradiotherapy and its correlation with treatment response and survival in patients with advanced esophageal squamous cell carcinoma

Preoperative serum C-reactive protein (CRP) levels have been shown to be of prognostic significance in patients with advanced esophageal carcinoma. However, the clinical significance of serum CRP levels in patients with unresectable or marginally resectable tumors in the absence of induction therapy has not been fully elucidated in relation to treatment response and prognosis. Thirty-four patients with clinical T3-T4 esophageal squamous cell carcinoma who underwent induction chemoradiotherapy (CRT) followed by esophagectomy were enrolled in this retrospective study. Serum CRP levels were measured during the course of CRT, i.e., prior to, during (1, 2, 3 and 4 weeks following initiation) and after CRT (prior to surgery). The association between CRP levels, CRT response and survival was analyzed. Elevated serum CRP levels exhibited a favorable decrease 2-3 weeks following CRT initiation in pathological responders and CRP ≤0.3 mg/dl at 2 and 3 weeks following CRT initiation, as well as prior to surgery, was significantly correlated with responders. In patients with pretreatment CRP >0.3 mg/dl (67.6% of patients in this study), CRP ≤0.3 mg/dl at 2 and 3 weeks following CRT initiation predicted responders with accuracies of 87.0 and 73.9%, respectively. In the univariate survival analysis, CRP levels 3 weeks following CRT initiation, as well as CRP levels prior to surgery and pathological stage, were significant prognostic factors, although CRP levels prior to surgery was the only independent prognostic factor in the multivariate analysis. Serum CRP levels during the course of CRT may be of prognostic and predictive significance for the CRT response in patients with unresectable or marginally resectable esophageal squamous cell carcinoma who undergo induction CRT.

COX-2 overexpression Induced by gene transfer reduces sensitivity of TE13 esophageal carcinoma cells to 5-fluorouracil and cisplatin

Previous clinicopathological studies demonstrated that overexpression of cyclooxygenase-2 (COX-2) is associated with a poor treatment response of esophageal carcinoma. The aim of this study was to elucidate the role of COX-2 overexpression in the chemosensitivity of esophageal carcinoma cells. TE13 human esophageal squamous cell carcinoma cells were transfected with a COX-2 constitutive expression vector, and stable transfectants overexpressing COX-2 were established. COX-2 overexpression in COX-2 transfectants was confirmed with western blotting and prostaglandin-E(2) (PGE(2)) assay. Chemosensitivity testing revealed that sensitivity of COX-2 transfectants to 5-fluorouracil and cisplatin was significantly lower than in control vector-only transfectants, and that sensitivity of COX-2 transfectants was restored by the transfection of COX-2-specific siRNA. In addition, expression of antiapoptotic B-cell lymphoma-extra large (BCL-xL) and myeloid cell leukaemia-1 (MCL-1) was increased in COX-2 transfectants. These results indicate that COX-2 overexpression may reduce the chemosensitivity of esophageal carcinoma cells through up-regulation of the expression of antiapoptotic BCL-2 family proteins.

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.

Overexpression of Interleukin-6 suppresses cisplatin-induced cytotoxicity in esophageal squamous cell carcinoma cells

Interleukin-6 (IL-6) expression at local tumor sites or in systemic circulation is associated with disease progression and poor prognosis of esophageal cancer. The aim of this study was to investigate the possible influence of IL-6 on biological activities of esophageal cancer cells in terms of chemosensitivity. Human esophageal cancer cell lines TE13 and KYSE170 were transfected with a plasmid vector expressing IL-6 and stable transfectants overexpressing IL-6 were thus established. The sensitivity of IL-6 transfectants to cisplatin was evaluated using a WST-8 assay and cell-cycle analysis. In addition, the inhibitory effects of IL-6-specific siRNAs were investigated. IL-6 transfectants showed significantly reduced sensitivity to cisplatin compared to control transfectants. In addition, the reduced cisplatin sensitivity of IL-6 transfectants was restored by pretreatment with IL-6-specific siRNA. These results suggest that intracellular IL-6 expression in tumor cells may acts as a resistance factor against cisplatin-based treatments for esophageal cancer.

[Early prediction of treatment response by serum CRP levels in patients with advanced esophageal cancer who underwent definitive chemoradiotherapy]

Serum CRP has been shown to be associated with the progression of esophageal cancer. The purpose of this study was to examine the relationship between treatment response and serum CRP levels in time course during definitive chemoradiotherapy (CRT) in terms of early prediction of CRT response by serum CRP. The subjects of this study were 36 patients with cT3/cT4 esophageal squamous cell carcinoma who underwent definitive CRT in our hospital. Serum CRP levels during definitive CRT (pretreatment, 1W, 2W and 3W after CRT initiation) were compared between CR and non-CR group. In addition, partition model was constructed to discriminate CR with non-CR and the prediction accuracy was evaluated. The patients were consisted of 28 males and 8 females. At pretreatment diagnosis, tumors were categorized as T3 (n=21) and T4 (n=15). Thirty four patients received FP-based chemotherapy and 2 patients received docetaxel-based chemotherapy. Treatment responses were categorized as CR (n=8), PR (n=14), NC (n=2) and PD (n=12). Serum CRP levels at the time of 2W after CRT initiation (CRT2W) in CR group were low compared to those in non-CR group (p=0.071). The partition model was constructed based on CRP levels at CRT2W. The prediction accuracies to discriminate CR from non-CR by CRP≤0.1 were 50%, 82%, and 75% in sensitivity, specificity and accuracy, respectively. Serum CRP is a useful biomarker for an early prediction of CRT response.

[Case of laparoscopic cholecystectomy for a double gallbladder]

A case of a double gallbladder, a congenital anomaly of biliary system is reported in a 71-year-old woman presenting with right hypochondrial pain. After a confirmed diagnosis of double gallbladder with gallstones was made by MRCP or ERCP, both gallbladders were removed laparoscopically. Double gallbladder is rare anatomic malformation of the biliary tract with only 88 cases, including ours, reported in the Japanese literature. Detailed preoperative investigations are required for an accurate preoperative diagnosis especially when considering laparoscopic removal to avoid inadvertent damage to biliary ductal system.

HMG-CoA reductase inhibitors reduce matrix metalloproteinase-9 activity in human varicose veins

Matrix metalloproteinases (MMPs) have been implicated in tissue degradation in varicose veins. The aim of this study was to investigate the effects of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) on the activity of MMPs in varicose veins. MMP-9 was present at significantly higher levels in varicose veins than in controls and was localized mainly in smooth muscle cells at the tunica media, where marked degradation of the extracellular matrix was observed. Both simvastatin and pravastatin strikingly suppressed MMP-9 activity in ex vivo culture of varicose veins. Simvastatin suppressed MMP-9 at both the mRNA and protein levels as well as at the urokinase-type plasminogen activator protein level, resulting in the dramatic suppression of MMP-9 activity induced by tumor necrosis factor-alpha. Therefore, statins suppress MMP-9 activity by multiple mechanisms in varicose veins, suggesting they may have clinical potential for the treatment of this disease.

Identification of a H+/glucose and galactose symporter gene glt from Xanthomonas oryzae pv. oryzae

We identified a glucose and galactose transporter gene from the plant-pathogenic bacterium Xanthomonas oryzae pv. oryzae. Sequence analysis indicated that the gene, named glt, encoded a polypeptide of 592 amino acid residues and the product was significantly homologous with members of the Na+/glucose cotransporter (SGLT) family from mammalian and bacterial origin, especially with vSGLT from Vibrio parahaemolyticus (50% identity). GLT functioned as a glucose and galactose transporter in an Escherichia coli mutant deficient in glucose and galactose transport activity. A protonophore inhibited the transport activity, suggesting that GLT is a H+-coupled glucose/galactose symporter.

Comparison of heavy metal concentrations in human umbilical cord in 1980 and 1990

The well-known Minamata disease was caused by mercury; the Itai-Itai disease by cadmium; and lead poisoning by gasoline additives. Following our previous investigation on heavy metal concentrations in the umbilical cords in 1980, total mercury, cadmium and lead concentrations in the umbilical cords (from 20 males and 20 females) have been measured in 1990 for comparison in the present study. The changes in metal concentrations in 1980 and 1990 were: from 0.007 +/- 0.005 microgram/g to 0.011 +/- 0.008 microgram/g for total mercury; from 0.019 +/- 0.016 microgram/g to 0.006 +/- 0.005 microgram/g, from 0.151 +/- 0.123 microgram/g to 0.046 +/- 0.038 microgram/g for lead. Total mercury accumulated in the umbilical cords increased to approximately 1.6-fold, while cadmium and lead decreased to approximately 1/3-fold during these 10 years.

Successful management of a giant spinal arteriovenous malformation with multiple communications between primitive arterial and venous structures by embolization: report of a case

A 47-year-old woman was admitted to our hospital with a giant spinal arteriovenous malformation (AVM) causing heart failure and thoracic myelopathy. Angiography revealed that the spinal AVM had multiple feeding vessels branching from the 5th through 12th intercostal arteries. The drainage vein flowed to the azygos vein and superior vena cava. The AVM destroyed the 7th thoracic vertebra. The cardiac output was 16.7l/min and the shunt ratio was 64% before treatment. Embolization with cyanoacrylate was performed because the operation was considered to be associated with a significant risk of paraplegia and organ ischemia. The cardiac output decreased to 11.6l/min and the shunt ratio was reduced to 32%. After embolization the patient demonstrated no symptoms of either heart failure or sensory deficits. During embolization, provocative tests using sodium amytal and lidocaine with magnetic stimulation were also performed. The above findings suggest that provocative tests and magnetic stimulation are useful to predict paraplegia, which could result from embolization while, in addition, embolization is considered to be a useful treatment for multiple shunt and nidus in this region.

Effect of E5510 on anastomotic intimal hyperplasia and platelet aggregation in dogs

We examined the effect of an antiplatelet agent, E5510, which inhibits both platelet aggregation and release of platelet-derived growth factor (PDGF), on anastomotic intimal hyperplasia and platelet aggregation. Twenty Beagle dogs underwent infrarenal aortic reconstruction with an expanded polytetrafluoroethylene (ePTFE) graft 5 mm in diameter and 3 cm long. The dogs were divided into three groups: placebo (control group, 7 dogs), E5510 1 mg/day (1-mg group, 6 dogs), and E5510 4 mg/day (4-mg group, 7 dogs). E5510 was administered orally 2 h before operation and once daily for 3 months after operation. Grafts were harvested 3 months after operation. All 13 grafts in the treated groups remained patent without evidence of intimal hyperplasia, whereas only 4 of 7 grafts (57%) remained patent in the control group, including 1 graft with > 50% stenosis. Three occluded grafts showed severe intimal hyperplasia at the anastomoses. The platelet aggregation ratio (PAR) with collagen (100 micrograms/ml) before drug administration at 3 months in the 4-mg group was significantly lower than that in the control and 1-mg groups. PAR after drug administration at 3 months in the 1- and 4-mg groups was significantly lower than that in the control group. Intimal thickness at the distal anastomosis was 817 +/- 190 microns in the control group, 240 +/- 80 microns in the 1-mg group, and 197 +/- 28 microns in the 4-mg group. Intimal thickness in the control group was significantly greater than that in the 1- and 4-mg groups. Smooth muscle cell (SMC) values in the intima at the distal anastomosis were 65.6 +/- 4.4% extinction (%E) in the control group, 47.6 +/- 3.4%E in the 1-mg group, and 51.3 +/- 3.5%E in the 4-mg group. SMC value in the control group was significantly greater than that in the 1- and 4-mg groups. E5510 inhibited PAR and reduced the degree of anastomotic intimal hyperplasia.

Changes in angiographic features and the ankle/brachial pressure index of femorodistal arterial bypass grafts during knee flexion

Systolic ankle pressure was measured in limbs in the extended and 90 degrees-flexed positions in three groups of patients who had undergone below-knee femorodistal arterial bypass. Group 1 consisted of eight limbs in seven patients who had received an autologous saphenous vein (ASV) graft; group 2 consisted of seven limbs in seven patients who had received a ringed expanded polytetrafluorethylene (ePTFE) graft; and group 3 consisted of five limbs in five patients who had received a reinforced biosynthetic borine collagen vascular (Omniflow) graft. Intravenous digital subtraction angiography was performed within 3 months of implantation. The ankle/brachial index (ABI) was significantly lower when the knee was flexed than when it was extended in group 1 and 3, but not in group 2. The ABI flexion in group 1 was similar to that in group 2. Morphologic changes such as kinking were demonstrated angiographically in groups 1 and 3. Given that the ABIs in groups 1 and 2 were similar with the knee flexed, despite the morphologic changes in group 1, we concluded that saphenous vein and ringed ePTFE grafts are more durable when subjected to acute knee flexion than Omniflow grafts. Thus, as graft failure is unlikely to result from kinking as a result of knee flexion alone, further clinical studies are required to elucidate the precise causes of graft failure.

Secular changes of PCB concentration accumulated in organs and tissues of Japanese from 1974 to 1989

The concentration and component types of PCB in adult human liver and fat tissue (64 samples) from forensic autopsy cases of Osaka Prefecture in 1989 were measured for comparison with the data for the same organ and tissue during the period from 1974 to 1984. The mean values of PCB levels in 1989 were 0.06 microgram/g (whole base) in the liver and 2.20 micrograms/g (fat base) in the fat tissue. These concentrations both were the same as those observed for the 15-year period. The percentages of the 5,6-chlorinated compound of PCB in the liver and fat tissue were lower but those of the 7-chlorinated compound were 15-20% higher.

Estimation of age from soft X-ray findings of Japanese pubic symphysis based on a image processing

A method for estimating the age at death through the image processing of soft X-ray pictures of pubic symphysis is reported. The collected 533 materials were sliced at the thickness of 5 mm. Prior to the image processing, subjective assessment was made on the five indices of gross morphological findings. The pictures showed roughening and darkening tendencies with age and two indices for image processing were introduced. Applying the natural logarithm to data obtained by the image processing and making regression analysis. two kinds of age estimation equations were derived in the form of; Y = -39.91 lnX + 189.63 and the estimated age Y was proportional to natural logarithm of measured indices X. The age estimation equations showed accuracies of 70% or more for the age range of +/- 5 years and 100% for +/- 8 years. The accuracy was satisfactory for age estimation in the field of person appraisal in legal medicine.

Estimation of age from image processing of soft X-ray findings in Japanese male thyroid cartilages

A method was developed for estimating the age at death based on image processing of soft X-ray pictures of thyroid cartilage from Japanese males. Data for 501 individuals were used to derive equations for this determination. Prior to image processing, gross morphological findings were used for estimation. Soft X-ray pictures indicated ossification with age and one index for image processing was introduced. The exponential function was applied to age estimation.

Estimation of age from soft X-ray findings of Japanese females thyroid cartilages

A method for estimating the age at death using the image processing of soft X-ray pictures of the thyroid cartilages of Japanese females was examined. The soft X-ray pictures showed increasing ossification with age. One index for image processing was introduced. It is ossification rate (OSFR). Corresponding to this index, one age estimation equation was obtained. This age estimation equation showed accuracies of 60% or more for the age range of +/- 5 years and about 80% for the age range of +/- 8 years.

Autopsy cases of giant heart during the past ten years in Osaka (1985-1994)

We collected data from 30 autopsied cases, in which the heart weight were 800 g or more (maximum 1,300 g), at the Osaka Medical Examiner's office, for past 10 years. Among these cases, the cause of death was cardiac failure in 17 cases (56.7%), followed by pulmonary diseases (3 cases, 10.0%), cerebral infarction (3 cases, 10.0%), and aortic rupture (2 cases, 6.6%). The mean weight of the giant hearts was 880 g (about 77% of the cases) and 4 cases (13%) had 1,000 g or more. The mean height of the giant heart victims was close to the standard level, and thus the mean level of the ratio of heart weight to height were about 2.5 times higher than the standard levels. The liver weights were also greater by 500-1,000 g than the standard levels.

Ringed grafting for an abdominal aortic aneurysm in a 92-year-old patient: report of a case

We report herein the case of a 92-year-old man with an abdominal aortic aneurysm who underwent successful surgical resection using a ringed graft. His postoperative course was uneventful, and he was discharged after 42 days, following which he attended the outpatient department twice a month for regular check-ups. He finally died of pneumonia which developed from an upper respiratory tract infection 6 months after his operation. Thus, surgical treatment should always be considered when an aneurysm is detected, even in very aged patients for whom the activities of daily living are possible.

[Study on secular changes of cadmium concentration accumulated in main organs of Japanese]

With the development of the mining and manufacturing industries and the petrochemical industry, cadmium (Cd) has been used not only for metal products but also petroleum products. Recently, environmental pollution due to waste fluids and gases from factories using cadmium and also domestic waste materials has become a cause for concern. In this connection, studies on the accumulated levels of Cd in the human body, its age-distribution in the general population and its secular changes during the last decade would be useful for clarifying the degree of contamination in the human body and providing an index which could be used as a basis for preventive measures against environmental pollution. For this purpose, the levels of Cd accumulated in main organs of the human body were determined using forensic data 3 times at 5-year intervals starting in 1976. The age intervals starting in 1976. The age group having the highest Cd level was 50-59 years, old and the mean weights of Cd per wet weight of heart, liver and kidney were 0.421, 2,984 and 56.43 micrograms/g, respectively. Each of these organs in babies less than a year old exhibited lower Cd levels, but teenagers had levels close to those in adult. However, the level in each organ was lower in individuals over 60 years old. 4 distinct age-related increase in the level of Cd was found only in the kidney. The levels of accumulated Cd in the liver and kidney showed a rise during the last 10 years from 2.358 to 5.568 micrograms/g and from 43.95 to 73.47 micrograms/g, respectively, whereas the Cd level in the heart has remained about the same, i.e. from 0.207 to 0.181 micrograms/g.

Studies on secular changes in the concentration of lead accumulated in organs and rib of Japanese

As environmental pollution due to waste fluids and gases from factories using lead (Pb), as well as domestic waste materials, has become a matter for public concern, studies on the accumulated levels of Pb in man have become necessary for defining the degree of contamination in the ordinary population. For this purpose, Pb levels in tissues of 76 forensic cadavers were determined in order to investigate the age distribution of accumulated Pb, and 120 samples were used to clarify secular changes in Pb accumulation during the last decade in the general population. The age group showing the highest Pb level was 50-59 years, with mean Pb contents per unit wet weight of 0.262, 0.520, 0.427 and 4.479 micrograms/g for heart, liver, kidney and rib, respectively. Each of these organs in all age groups exhibited almost the same Pb levels, but babies less than one year old had levels close to those in adults. However, ribs in babies exhibited much lower Pb levels. The levels in each organ were lower in individuals over 60 years old. A distinct age-related increase in Pb levels was found only in ribs from age 0 year to 50-59 years. The Pb levels in the heart, liver, kidney and rib showed a decrease during the last 10 years from 0.188 +/- 0.073 to 0.006 +/- 0.003 micrograms/g, from 0.307 +/- 0.169 to 0.076 +/- 0.057 micrograms/g, from 0.287 +/- 0.145 to 0.021 +/- 0.011 micrograms/g and from 3.203 +/- 1.477 to 2.366 +/- 1.469 micrograms/g, respectively.

[The fate of patients with intermittent claudication-comparison of surgical and non-surgical treatment]

The purpose of this study was to determine the operative indication for patients with intermittent claudication because of arteriosclerosis obliterans, and to compare the late result of the surgical treatment group (182 cases, 250 limbs) with that of the non-surgical treatment group (35 cases, 43 limbs). There were 3 operative deaths and 34 late deaths in the surgical group, and 14 late deaths in the non-surgical group. The number one cause of death was heart failure, including ischemic heart disease, in both groups. The 4-year cumulative patency rates were 91% in the aorto-iliac, 71% in the femoro-distal and 79% in the aorto-femoro-distal arterial reconstructions. Long term symptom free rates of the surgical group and the non-surgical group, except fatal case, were 83% and 44% in the aorto-iliac, 79% and 27% in the femoro-distal, 87% and 33% in the aorto-femoro-distal arterial regions, respectively. Late result of intermittent claudication in the surgical group was better than that in the non-surgical group. We concluded that intermittent claudication should be considered to be the indication for surgery, except for the cases with high risk diseases or malignant diseases.