Prognostic nomogram for nonresectable pancreatic cancer treated with gemcitabine-based chemotherapy

Background:

A nomogram is progressively being used as a useful predictive tool for cancer prognosis. A nomogram to predict survival in nonresectable pancreatic cancer treated with chemotherapy has not been reported.

Methods:

Using prospectively collected data on patients with nonresectable pancreatic cancer receiving gemcitabine-based chemotherapy at five Japanese hospitals, we derived a predictive nomogram and internally validated it using a concordance index and calibration plots.

Results:

In total, 531 patients were included between June 2001 and February 2013. The American Joint Committee on Cancer (AJCC) TNM stages were III and IV in 204 and 327 patients, respectively. The median survival time of the total cohort was 11.3 months. A nomogram was generated to predict survival probabilities at 6, 12, and 18 months and median survival time, based on the following six variables: age; sex; performance status; tumour size; regional lymph node metastasis; and distant metastasis. The concordance index of the present nomogram was higher than that of the AJCC TNM staging system at 12 months (0.686 vs 0.612). The calibration plots demonstrated good fitness of the nomogram for survival prediction.

Conclusions:

The present nomogram can provide valuable information for tailored decision-making early after the diagnosis of nonresectable pancreatic cancer.

Multicenter phase II study of gemcitabine (GEM) plus S-1 in patients (pts) with advanced biliary tract cancer (BTC)

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Background: Pts with advanced BTC have a poor prognosis and no standard palliative chemotherapy has been defined. The purpose of this prospective multicenter phase II study was to evaluate the efficacy and safety of GEM plus S-1 combination therapy in pts with advanced BTC. Methods: Pts with advanced BTC, with at least one measurable lesion were eligible for this study. Other eligibility criteria included: no previous palliative chemotherapy, ECOG performance status ≤ 2, and adequate organ function. S-1 was given orally at a dose of 80mg/m2 daily from day 1 to day 14. GEM was given intravenously at a dose of 1,000mg/m2 over 30 min on day 1 and day 15, repeated every 4 weeks. Tumor response was the primary endpoint and was assessed according to RECIST every 8 weeks. Planned sample size was 35 according to Simon's two stage method. Results: 35pts were enrolled: median age 67; M/F (22/13); ECOG performance status 0/1/2 (16/18/1). The primary tumor site was; 14 pts in gallbladders, 14 pts in intrahepatic bile ducts, 6 pts in extrahepatic bile ducts, and 1 pt in Vater of papilla. Seven pts had previous surgical resection. Complete and partial responses were achieved in 2 and 9 pts, respectively. Eighteen pts had stable disease. Overall response rate was 31.4% and overall disease control rate was 82.9%. The median TTP was 6.1 months (95%CI, 4.0–8.1 months) and the overall survival was 11.7 months (95%CI, 7.3- months). The grade 3/4 toxicities were: neutropenia (31.4%), anemia (17.1%), thrombocytopenia (2.9%), anorexia (2.9%). No treatment-related deaths occurred during the study. Conclusions: GEM plus S- 1 combination therapy showed promising efficacy and good tolerability in pts with advanced BTC.

No significant financial relationships to disclose.

Self-expandable metallic stents for malignant biliary obstruction with an anomalous pancreaticobiliary junction

BACKGROUND

Anomalous pancreaticobiliary junction (APBJ) is associated with pancreaticobiliary cancer. Limited data are available on endoscopic biliary drainage for unresectable malignant biliary obstruction with APBJ. This study evaluated the efficacy and safety of self-expandable metallic stents (EMSs) for the management of malignant biliary obstruction with APBJ.

METHODS

Between 1993 and 2005, 324 patients with unresectable malignant biliary obstruction underwent insertion of an EMS. Six of these patients with concomitant APBJ constituted the subjects of this study. Early (</=30 days after EMS insertion) and late (>30 days after EMS insertion) stent-related complications and stent patency were evaluated in these six patients.

RESULTS

The cause of biliary obstruction was gallbladder cancer in four patients and pancreatic cancer in two patients. Uncovered EMSs were inserted across the common channel without performance of a biliary sphincterotomy. The diameter of the uncovered EMS used was based on the diameter of the common channel. For all six patients, endoscopic biliary drainage was successful, and their jaundice subsided steadily. None of the six patients experienced early complications, including acute pancreatitis. The mean stent-related complication-free period was 163 days. Stent occlusion caused by tumor ingrowth occurred in two patients. Acute cholangitis and cholecystitis were observed in one patient each.

CONCLUSIONS

Uncovered EMSs are effective for palliation of unresectable malignant biliary obstruction in patients who have APBJ without increasing the risk of stent-related early complications.

Development of a novel microbial sensor with baker's yeast cells for monitoring temperature control during cold food chain

A novel microbial sensor containing a commercial baker's yeast with a high freeze tolerance was developed for visibly detecting inappropriate temperature control of food. When the yeast cells fermented glucose, the resulting gas production triggered the microbial sensor. The biosensor was a simple, small bag containing a solution of yeast cells, yeast extract, glucose, and glycerol sealed up with multilayer transparent film with barriers against oxygen and humidity. Fine adjustment of gas productivity in the biosensor at low temperatures was achieved by changing either or both concentrations of glucose and yeast cells. Moreover, the amount of time that food was exposed to inappropriate temperatures could be deduced by the amount of gas produced in the biosensor. The biosensor was stable without any functional loss for up to 1 week in frozen storage. The biosensor could offer a useful tool for securing food safety by maintaining low-temperature control in every stage from farm to fork, including during transportation, in the store, and at home.

Strongyloidiasis in a patient with acquired immunodeficiency syndrome

Rhabditiform larvae, transforming larvae from rhabditiform to filariform, and eggs of Strongyloides stercoralis were identified in the sputum of a Thai woman with acquired immunodeficiency syndrome (AIDS), and stool microscopy also showed a heavy load of rhabditiform larvae of S. stercoralis. She was treated with 12 mg ivermectin once a day for 2 days for the strongyloidiasis, with good therapeutic results being obtained. Strongyloidiasis may be a curable disease through the use of an appropriate therapy, even in a patient with AIDS.

The use of needlescopic instruments in laparoscopic ventral hernia repair

A successful laparoscopic hernia repair requires complete covering of the hernia defect, adequate tension of the prosthesis, and secure stapling with a stapler. We describe herein our technique of performing laparoscopic hernia repair using a needlescopic instrument which results in minimal damage to the abdominal wall and has significant cosmetic benefits. Our technique is easy to perform and useful for achieving initial anchoring of the prosthesis before fixation to the abdominal wall with a laparoscopic stapler.

Laparoscopic intragastric stapled resection of gastric submucosal tumors located near the esophagogastric junction

BACKGROUND

Laparoscopic resection cannot be applied easily to tumors located near the esophagogastric junction or the pyloric ring. We evaluated our laparoscopic intragastric surgical technique for gastric submucosal tumors located near the esophagogastric junction and the results of a clinical study.

MATERIALS AND METHODS

We performed our technique in six patients: one man and five woman with a mean age of 61 years. Using the laparoscopic procedure, after inflation of the stomach, we inserted two or three balloon-type ports into the stomach through the abdominal wall.

RESULTS

A stapled resection of gastric submucosal tumors using a laparoscopic linear stapler was performed successfully in all the patients. Without exception, stapled resections were successfully performed. The mean operation time was 168 min, and the blood loss was minimal There were no intra- or postoperative complications. The mean postoperative hospital stay was 9.8 days. The mean maximal diameter size of the resected specimens was 2.4 cm. Histopathologic diagnoses were gastrointestinal stromal tumors in five cases and enterogenous cyst in one. There were no recurrences during a mean follow-up period of 27 +/- 11.6 months.

CONCLUSION

Although we need to evaluate the long-term outcomes, our procedure is considered technically feasible, safe, and useful for the resection of gastric submucosal tumors located near the esophagogastric junction.

Laparoscopic intragastric resection of gastric leiomyoma using needlescopic instruments. Case report

Laparoscopic intragastric resection of gastric leiomyoma was performed using needlescopic instruments. The patient was a 71-year-old man who had a 2-year history of gastric submucosal tumor 2 cm in diameter located near the esophagocardiac junction. After getting informed consent, we performed a laparoscopic intragastric tumor resection under an oral endoscope. There were no intra- or postoperative complications. The patient was discharged uneventfully. Histopathologic diagnosis of the tumor was leiomyoma. Laparoscopic intragastric resection of a benign gastric submucosal tumor using needlescopic instruments is technically feasible and as safe as a less invasive procedure.

Technical report: a technique of rapidly re-establishing a pneumoperitoneum with use of a wound protector during laparoscopic-assisted surgery

The authors described a technique of rapidly reestablishing a pneumoperitoneum after laparoscopically assisted surgery by pulling up and clamping the edge of the wound protector. Our laparoscopic assisted surgical technique for the digestive tract is useful and easy to perform without using special devices.

The use of double-straight needle device in laparoscopic incisional and ventral hernia repair

Incisional and ventral hernias are good indications for laparoscopic hernia repair. A successful repair requires complete covering of the hernia defect, adequate tension of the prosthesis, and secure stapling by a hernia stapler. The authors introduce their technique using a double-straight needle device. This technique is easy and quick and achieves adequate fixation between the prosthesis and the abdominal wall, which reduces operating time and provides cosmetic benefit.

Laparoscopic duodenal diverticulectomy

We report a case of successful laparoscopic resection of a diverticulum with gastrointestinal bleeding at the third portion of the duodenum. The patient was a 76-year-old man who suffered from persistent tarry stools. An upper gastrointestinal series and endoscopy revealed a large diverticulum with an ulcer and blood clots located at the lateral wall of the distal third portion of the duodenum. Under general anesthesia, a pneumoperitoneum was created by insufflating the abdominal cavity with CO2. There were dense adhesions caused by a previous open cholecystectomy. Four trocars were inserted into the peritoneal cavity for this procedure. After dissecting and identifying the duodenal diverticulum, we performed a diverticulectomy, using an Endo-GIA linear stapler at the base of the retracted diverticulum. There were no intra- or postoperative complications. The operative time was 180 min. Intraoperative bleeding was minimal. Postoperative duodenogram revealed no deformity or stenosis at the resected area. The patient was discharged after an uneventful course, and he has been doing well with no complaints during the follow-up period.

Experience with three-port laparoscopic cholecystectomy

After considerable experience with laparoscopic cholecystectomy (LC) using four ports, we began using three-port LC in October 1993 and have performed 130 LCs with this procedure up to May 1996. The procedure was successful in 119 patients. In 6 patients fourth port was used, and in another 5, the procedure was converted to open laparo-tomy. Cooperative manipulation of the surgical instruments between the operator and assistant is very important for this procedure, for exposing Calot's triangle and dissecting the gallbladder from the gallbladder bed. The use of an ultrasonic aspiration system (Sumisonic ME 2400; Sumitomo Bakelite, Tokyo, Japan) made it easier to identify the cystic duct and artery, especially in patients with chronic inflammation or dense adhesions. We encountered no problems with cannulation into the cystic duct for intraoperative cholangiography, and there were no intra- and postoperative complications in this series. We achieved good results, similar to those achieved with the four-port technique. This technique is technically feasible and safe, and it has esthetic and cost advantages compared with the four-port technique. However, the operator who performs three-port LC should not hesitate to add another port, or to convert to open laparotomy, whenever any difficulties occur during this procedure, to prevent critical complications.

Mechanical reactivity of isolated human and guinea-pig portal veins to spasmogens

The pattern of mechanical reactivity to prostaglandin F2 alpha and endothelin-1 was different in circular muscle preparations of the extra-hepatic portal vein of humans and guinea-pigs.

Laparoscopic local resection for benign nonepithelial gastric tumors

After experience in laparoscopic cholecystectomy and improvement of laparoscopic instruments, we attempted laparoscopic resection of benign nonepithelial gastric tumors using Endo-GIA. We achieved successful results with this procedure in 2 cases. There were no intra- and postoperative complications. For both patients there was no recurrence during the follow-up period (3.3 and 1.5 years). The important points of this approach are confirmation of the location of the tumor by both gastroendoscopy and laparoscopy, proper selection of the trocar site for insertion of the Endo-GIA, and secure grasping and lifting of the gastric wall, including of the tumor. We conclude that this procedure is technically feasible, safe and useful for benign nonepithelial gastric tumors.

Laparoscopic repair of an abdominal hernia using an expanded polytetrafluoroethylene patch secured by a four-corner tacking technique

An improved technique for performing laparoscopic repair of an abdominal hernia is described herein. To ensure a successful repair, it is most important that adequate tension of the expanded-polytetrafluoroethylene (e-PTFE) patch be achieved, and that the defect be completely covered and securely stapled. Our technique involves tacking the four corners of the patch to the abdominal wall with a 2-0 nylon suture using a straight needle, then stapling it to the anterior abdominal wall over the defect with a laparoscopic stapler. We believe that this technique is a safe and reliable method which will prove useful for laparoscopic surgery.

Laparoscopic transabdominal preperitoneal herniorrhaphy using abdominal wall-lifting method under regional anesthesia: a preliminary report

This report describes a laparoscopic transabdominal preperitoneal herniorrhaphy of groin hernias using an abdominal wall-lifting method under regional anesthesia as compared with pneumoperitoneum under general anesthesia. The series of studies involved the repair of 20 groin hernias; 7 hernias were direct, 11 were indirect, and 2 were femoral. These included 7 recurrent, 1 incarcerated, and 4 bilateral hernias. There were no intraoperative complications, and both procedures required no conversion to open surgery. There are no significant differences between the two groups in operative time and postoperative hospital stay. The only postoperative complication of our procedure was temporary inguinal pain in 2 cases. The follow-up period ranged from 8 to 17 months. To date, no recurrence has developed. We conclude that our procedure is a safe, technically feasible, and useful method to perform laparoscopic herniorrhaphy for groin hernias.

Successful surgical treatment of secondary Kwashiorkor after total gastrectomy: report of a case

We report herein the case of a 56-year-old woman who developed secondary Kwashiorkor 9 years after undergoing a total gastrectomy for early gastric cancer. Until she began developing the symptoms of Kwashiorkor, including general fatigue, edema of the face and extremities, anemia, alopecia, and weight loss, she had been leading a normal life post-gastrectomy. Her symptoms were alleviated by total parenteral nutrition (TPN) therapy, but reappeared soon after TPN therapy was discontinued. Therefore, she required several subsequent courses of TPN. In an attempt to permanently resolve the ongoing Kwashiorkor symptoms, reconstructive surgery involving transposition of the jejunum from the previous Graham method to the interposition method was performed 10 years after the initial gastrectomy. After the second operation, her malnutrition was completely alleviated, and she has been in good health for the 8 years since. To our knowledge, there has been no other report of the symptoms of secondary Kwashiorkor after total gastrectomy being alleviated by altering the procedure of reconstruction of the intestinal tract. Thus, we recommend surgical treatment to alter the digestive continuity to a more physiological pathway for selected patients with secondary Kwashiorkor syndrome.

[Biliary tract infection]

Biliary tract infection is a frequently encountered clinical problem and requires prompt diagnosis, proper understanding of the pathologic manifestations, and adequate treatment. If not managed properly, it can be the cause of disseminated intravascular coagulation and multiple organ failure and its prognosis can be fatal. This paper focuses on two of its representative diseases: acute cholecystitis and acute cholangitis.

MR findings of surgically retained sponges and towels: report of two cases

MR findings of surgically retained sponges (gossypiboma) in two patients are reported. The sponges were well-encapsulated round masses with a thick wall of low signal intensity on both T1-weighted images (T1WI) and T2-weighted images (T2WI). The signal intensity of the center of the masses varied in both patients on T1WI and T2WI. In one patient, the mass was high in signal intensity on both T1- and T2-weighted images and had a low signal intensity whirl that represented a surgical sponge. The sponge was rich in serosanguinous fluid with a high protein concentration (8.2 g/dl). In the other patient, the mass was low in signal intensity on both T1- and T2-weighted images, and was mainly composed of organized cotton matrix with little fluid. The protein concentration of the fluid was lower than in the former case (6.4 g/dl).

[Study on the concentrations of 5-fluorouracil (5-FU), tegafur (ET) and uracil in bile: comparison of UFT or FT]

The serum and bile tegafur (FT), 5-fluorouracil (5-FU) and uracil levels after administration of UFT were assessed in 13 cases of malignant biliary tumor accompanied by biliary obstruction in comparison with FT alone. The serum and bile FT and 5-FU levels showed almost the same transition pattern in both groups, reaching to the plateau in 1-2 weeks and revealing cumulative effect by continual administration. Correlation was obtained between serum and bile levels except for 5-FU level in UFT group (p less than 0.05). Correlation between 5-FU and uracil was obtained in the serum in both groups (p less than 0.05), but no effect of uracil was observed. In bile, correlation was seen only in UFT group (p less than 0.05), and the effect of uracil was observed in bile 5-FU level.