Short-term outcomes of pancreatoduodenectomy in older individuals over a 9-year period using real-world data: A multilevel analysis based on a nationwide administrative database in Japan

BACKGROUND

We aimed to evaluate the short-term outcomes of pancreatoduodenectomy (PD) in older individuals.

METHODS

Data from the Japanese Diagnosis Procedure Combination database on 62 275 patients who underwent PD from 1 April 2012 to 31 March 2020 were analyzed. Patients were divided into five age groups: <70, 70-74, 75-79, 80-84, and ≥85 years. The associations between postoperative outcomes and age were investigated using multilevel analysis. The mean differences in length of hospital stay and cost were also compared.

RESULTS

The rate of PD in older individuals increased annually. Compared with the youngest age group (< 70 years), the incidence rate ratios for in-hospital mortality were 1.52 (95% confidence interval [CI]: 1.30-1.76), 2.07 (1.82-2.37), 2.29 (1.94-2.71), and 2.92 (2.20-3.87) in the 70-74, 75-79, 80-84, and ≥ 85-year-old age groups, respectively (all p < .001). Postoperative complications, length of postoperative hospital stay, and cost increased significantly with increasing age.

CONCLUSIONS

These real-world data emphasize the higher levels of morbidity, mortality, and cost in older patients. Careful attention should be paid when considering the indication for PD in older individuals.

Laparoscopic approach for port site mass diagnosed as a Schloffer tumor following surgery of ascending colon cancer

Schloffer tumor is a foreign body granuloma that develops in the subcutaneous layer of the abdomen over several months to several years after surgery due to sutures. Here, we performed a laparoscopic resection for a benign Schloffer tumor that showed positive F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) at the port site of a laparoscopic right hemicolectomy for advanced colon cancer. We report a case in which systemic chemotherapy was avoided as a result of the histological examination following the laparoscopic approach. A 66-year-old female, who underwent laparoscopic right hemi colectomy for stage IIIA ascending colon cancer, was revealed an enhanced mass at the right side of the abdominal subcutaneous layer. PET examination showed a high accumulation of FDG. Laparoscopic tumor resection was performed. Pathological findings reported the formation identical to the Schloffer tumor. Schloffer tumor, which is rare, should be considered as one of the differential diagnoses for tumor with FDG-PET positivity at the port site during the postoperative surveillance period of colorectal cancer.

Validation study of a skill assessment tool for education and outcome prediction of laparoscopic distal gastrectomy

BACKGROUND

The Japanese operative-rating scale for laparoscopic distal gastrectomy (JORS-LDG) was developed through cognitive task analysis together with the Delphi method to measure intraoperative performance during laparoscopic distal gastrectomy. This study aimed to investigate the value of this rating scale as an educational tool and a surgical outcome predictor in laparoscopic distal gastrectomy.

METHODS

The surgical performance of laparoscopic distal gastrectomy was assessed by the first assistant, through self-evaluation in the operating room and by video raters blind to the case. We evaluated inter-rater reliability, internal consistency, and correlations between the JORS-LDG scores and the evaluation methods, patient characteristics, and surgical outcomes.

RESULTS

Fifty-four laparoscopic distal gastrectomy procedures performed by 40 surgeons at 16 institutions were evaluated in the operating room and with video recordings using the proposed rating scale. The video inter-rater reliability was > 0.8. Participating surgeons were divided into the low, intermediate, and high groups based on their total scores. The number of laparoscopic surgeries and laparoscopic gastrectomy procedures performed differed significantly among the groups according to laparoscopic distal gastrectomy skill levels. The low, intermediate, and high groups also differed in terms of median operating times (311, 266, and 229 min, respectively, P < 0.001), intraoperative complication rates (27.8, 11.8, and 0%, respectively, P = 0.01), and postoperative complication rates (22.2, 0, and 0%, respectively, P = 0.002).

CONCLUSIONS

The JORS-LDG is a reliable and valid measure for laparoscopic distal gastrectomy training and could be useful in predicting surgical outcomes.

The Pitfall of VA ECMO management in the Impella era

Introduction

VA ECMO is effective in cardiogenic shock, but complications of cardiogenic pulmonary edema due to increased afterload are problematic. The advent of percutaneous left ventricular assist devices (Impella) has enabled effective reduction of left ventricular intraventricular pressure and has avoided these complications, but differential hypoxia can still occur during VA ECMO + Impella (Ecpella) management, requiring conversion to V-AV ECMO. Cases may be experienced.

Purpose

Elucidate the frequency of differential hypoxia and its pathogenesis, which requires the transition from VA ECMO to V-AV ECMO.

Methods

We retrospectively reviewed 52 consecutive patients who underwent E-CPR from January 2017 through November 2021 in our institute. 8 patients who received ECMO alone were excluded, and 44 patients were recruited. 22 patients underwent VA ECMO with IABP (VA ECMO + IABP group) and 22 patients underwent VA ECMO with Impella (VA ECMO + Impella group). The 30-day survival rate and the rate of transition VA ECMO to VA-V ECMO, The date just before VA ECMO to V-AV ECMO were assessed.

Results

The 30-day all-cause mortality was no significant difference between the two groups. 2 patients (9%) in the VA ECMO + IABP group and 8 patients (36%) in the VA ECMO + Impella group were transferred to V-AV ECMO (P=0.025). At the time of addition of V-AV ECMO, SaO2 (right radial artery) was 87±7.1% and 91.3±1.9% (p=0.112) in the VA ECMO + IABP and VA ECMO + Impella groups, respectively, and the P/F ratio was 86±37.1 and 95±24.6 (p=0.685). Mean pulmonary artery wedge pressure was 23±1.4 mmHg in the VA ECMO + IABP group and 16.3±3 mmHg in the VA ECMO + Impella group (p=0.0193), significantly lower in the Impella group.

Conclusion

The Impella group was more likely to have hypoxia due to factors other than cardiogenic pulmonary edema. In cases of cardiopulmonary arrest requiring V-AV ECMO management, differential hypoxia due to causes other than cardiogenic pulmonary edema may become apparent earlier in the Impella group, suggesting that careful management, including the addition of V-AV ECMO, is required.

Funding Acknowledgement

Type of funding sources: None.

An advanced bipolar device helps reduce the rate of postoperative pancreatic fistula in laparoscopic gastrectomy for gastric cancer patients: a propensity score-matched analysis

BACKGROUND

Advanced bipolar devices (ABD; e.g., LigaSure™) have a lower blade temperature than ultrasonically activated devices (USAD; e.g., Harmonic® and Sonicision™) during activation, potentially enabling accurate lymph node dissection with less risk of postoperative pancreatic fistula (POPF) due to pancreatic thermal injury in laparoscopic gastrectomy. Therefore, we compared the efficacy and safety of ABD and USAD in laparoscopic gastrectomy for gastric cancer patients.

METHODS

A retrospective cohort study was conducted on patients who underwent laparoscopic distal gastrectomy (LDG) between August 2008 and September 2020. A total of 371 patients were enrolled, and short-term surgical outcomes, including the incidence of ISGPF grades B and C POPF, were compared between ABD and USAD. The risk factors for POPF in LDG were investigated by univariate and multivariate analyses.

RESULTS

A propensity score-matching algorithm was used to select 120 patients for each group. The POPF rate was significantly lower (0.8 vs. 9.2%, p < 0.001), the morbidity rate was lower (13.3 vs. 28.3%, p < 0.001), the length of postoperative hospitalization was shorter (14 vs. 19 days, p < 0.001), and the lymph node retrieval rate was higher (34 vs. 26, p < 0.001) with an ABD than with a USAD. There were no mortalities in either group. A multivariate analysis showed that a USAD was the only independent risk factor with a considerably high odds ratio for the occurrence of POPF (USAD/ABD, odds ratio 8.38, p = 0.0466).

CONCLUSION

An ABD may improve the safety of laparoscopic gastrectomy for gastric cancer patients.

Evaluation of cholecystectomy in older individuals using real-world data: a multilevel analysis based on a nationwide administrative database in Japan

BACKGROUND

In the present study, we aimed to evaluate the clinical outcomes of cholecystectomy in older individuals.

METHODS

In this retrospective study, data from the Japanese Diagnosis Procedure Combination database on 96,620 patients who had undergone cholecystectomy at 1060 hospitals from 2018 to 2020 were analyzed. Patients were divided into five age groups: < 75, 75-79, 80-84, 85-89, and ≥ 90 years. Associations between postoperative outcomes and age group were investigated by logistic regression analysis. Mean differences between age groups in time to postoperative recovery and cost were also compared.

RESULTS

Older patients had higher rates of poor scores for activities of daily living and preoperative comorbidity. Compared with the youngest age group (< 75 years), the odds ratios for in-hospital mortality were 3.00 (95% confidence interval, 1.74-5.19), 7.54 (4.73-12.01), 13.47 (8.21-22.14), and 27.64 (15.56-49.09), in the 75-79, 80-84, 85-89, and ≥ 90-year-old age group, respectively (all p < 0.001). Furthermore, the length of postoperative hospital stay and rates of postoperative complications, postoperative reintubation, and reoperation with general anesthesia increased significantly in parallel with increasing age, the highest rates being in the ≥ 90 year-old age group.

CONCLUSIONS

Our real-world data highlight the worse postoperative outcomes, including a higher mortality rate, in older patients undergoing cholecystectomy. Care should be taken when considering the indications for surgery in such patients.

A phase II multicenter trial assessing the efficacy and safety of first-line S-1 + ramucirumab in elderly patients with advanced/recurrent gastric cancer: KSCC1701

BACKGROUND

The mainstream first-line chemotherapy for advanced/recurrent gastric cancer (ARGC) is combination therapy including platinum-based agents. With the progressive aging of the society, the incidence of gastric cancer in elderly patients is increasing. However, elderly patients cannot tolerate these agents because of renal dysfunction or low quality of life. The KSCC1701 study explored the efficacy and safety of S-1 + ramucirumab in elderly patients with ARGC.

PATIENTS AND METHODS

Chemotherapy-naive patients aged ≥70 years with ARGC were eligible. Patients received S-1 (40-60 mg twice daily for 4 weeks in 6-week cycles) and ramucirumab (8 mg/kg every 2 weeks) until disease progression. The primary end-point was the 1-year overall survival (OS) rate. The anticipated lower threshold of 1-year survival was set at 40% in light of previous S-1-based regimens. The secondary end-points included progression-free survival (PFS), OS, the overall response rate (ORR) and safety.

RESULTS

Between September 2017 and November 2019, 48 patients (34 men and 14 women) were enrolled in this study. The median patient age was 77.5 years, and all patients had a performance status of 0 (n = 20) or 1 (n = 28). The 1-year OS rate was 65.2%, which met the primary end-point. The median survival time and median PFS were 16.4 and 5.8 months, respectively. The ORR was 41.9%. The most frequent grade 3/4 (≥15%) adverse events were neutropenia, anorexia and anaemia.

CONCLUSION

Considering these findings, S-1 + ramucirumab appears to be an excellent treatment option for elderly patients with ARGC. (250 words). This trial has been registered with the Japan Registry of Clinical Trials Registry under the number jRCTs071180066.

Geriatric-8 (G8) screening tool stratified the efficacy of S-1 plus ramucirumab in elderly patients with advanced/recurrent gastric cancer: A post-hoc analysis of the KSCC1701 trial

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Background: KSCC1701 trial showed the efficacy and safety of S-1 plus ramucirumab as a first-line treatment for elderly patients with advanced/recurrent gastric cancer. However, some frail patients may not benefit from S-1 plus ramucirumab. We aimed to clarify the usefulness of G8 screening tool for stratifying the efficacy and safety of S-1 plus ramucirumab therapy to elderly patients with advanced/recurrent gastric cancer. Methods: Patients aged 70 and older with previously untreated unresectable or recurrent gastric cancer were included from 23 institutes in Japan. They received S-1 (40-60 mg twice daily for 28 days, every 6 weeks) plus ramucirumab (8 mg/kg, every 2 weeks) until disease progression. The primary endpoint was the one-year survival rate. The secondary endpoints included progression-free survival (PFS), overall survival (OS), response rate (RR), and safety. The exploratory endpoint was detection of differences in treatment response by G8 screening tool. Results: Between September 2017 and November 2019, 48 patients were enrolled in this study. The cut-off value of G8 was determined as 11 by time-dependent ROC curve analysis for OS. Patients of G8 high (> = 11) and low (< 11) were 31 and 15, respectively. The characteristics of patients with G8 high/low were male: 21 (65.6%)/13 (81.3%), median age: 77/78 years, and PS (0): 16 (50.0%)/4 (25.0%). The one-year survival rate (total/G8-high/G8-low) was 65.2%/82.6%/26.7%. The median OS and PFS (total/G8-high/G8-low) were 16.4/20.7/6.9 months and 5.8/7.2/3.9 months, respectively. On Cox proportional hazards regression analysis for OS and PFS, the hazard ratio of G8-high was 0.156 [95%CI:0.066-0.367 (p < 0.0001)] and 0.391 [95%CI:0.202-0.755 (p = 0.0038)], respectively. The best RR (total/G8-high/G8-low) was 41.9%/55.6%/23.1%. The frequent grade 3 adverse events (total/G8-high/G8-low) was 78.7%/77.4%/81.3%. The frequent grade 4 adverse events (total/G8-high/G8-low) was 14.9%/16.1%/12.5%. Conclusions: Based on the results, G8 screening tool is useful for selecting elderly patients with advanced/recurrent gastric cancer in whom S-1 plus ramucirumab treatment shows a longer survival and a higher RR. Further examination including adverse events is therefore warranted. Clinical trial information: UMIN000028309.

A multicenter phase II study of S-1 plus ramucirumab as first-line treatment in elderly patients with advanced/recurrent gastric cancer (KSCC1701)

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Background: Elderly patients are often intolerable in the combination with cytotoxic agents. Therapy with S-1 alone is a key option for initial chemotherapy for Japanese elderly patients with unresectable gastric cancer in clinical practice. However, there are some cases in which the antitumor effects with S-1 alone are insufficient. We aimed to investigate the efficacy and safety of S-1 plus ramucirumab therapy to elderly patients with advanced/recurrent gastric cancer. Methods: Patients aged 70 years and older with previously untreated unresectable or recurrent gastric cancer patients were included in Japan. They received S-1 therapy (40-60 mg twice daily for 28 days, every 6 weeks) plus ramucirumab therapy (8 mg/kg, every 2 weeks) until disease progression. The primary endpoint was the one-year survival rate and null hypothesis of one-year survival was set as 40%, which is the lower bound of the 95% confidence interval in previously reported studies on S-1 therapy. The secondary endpoints included progression-free survival (PFS), overall survival (OS), response rate (RR), and safety. Results: Between September 2017 and November 2019, 48 patients were enrolled in this study. The characteristics of patients were male/female: 34/14, median age: 77.5 years (range: 71-87), and PS (0/1): 20/28. The one-year survival rate was 65.2% (95% confidence interval 49.8-78.6%), which means this trial met the primary endpoint. The median OS and PFS were 16.4 months (95%CI:12.0–20.7) and 5.8 months (95%CI:4.0–7.2), respectively. The best RR (CR+PR) was 60.9%. The frequent grade 3 or grade 4 adverse events were neutropenia (27.7%), anorexia (23.4%), anemia (19.1%), hypertension (14.9%), leucopenia (12.8%) and hypoalbuminemia (12.8%). Conclusions: Based on the observed efficacy and safety, S-1 plus ramucirumab is an appropriate first-line treatment for elderly patients with advanced/recurrent gastric cancer. Clinical trial information: UMIN000028309.

Clinical Outcomes of Laparoscopic Versus Laparotomic Distal Gastrectomy in Gastric Cancer Patients: A Multilevel Analysis Based on a Nationwide Administrative Database in Japan

BACKGROUND

The present study compared the short-term outcomes and costs of laparoscopic distal gastrectomy (LDG) with those of open distal gastrectomy (ODG) for gastric cancer using a nationwide administrative database in Japan.

METHOD

Overall, 37,752 patients with gastric cancer who underwent distal gastrectomy at 1074 hospitals in the fiscal year 2012-2013 were evaluated using a diagnosis procedure combination database in Japan. We performed a retrospective analysis via a multilevel analysis (MLA) of the short-term surgical results and costs of the LDG and ODG groups. The models included the age, sex, comorbid complications, smoking, body mass index (BMI), activity of daily living (ADL), stage, and the number of cases of gastrectomy per facility for adjustment. The in-hospital mortality relative to the hospital volume was also compared.

RESULTS

The LDG group required postoperative blood transfusion less frequently and had fewer postoperative complications, shorter hospitalization, and lower operative mortality than the ODG group. While this stage did not correlate with the in-hospital mortality, the surgical method, age, sex, ADL, BMI, comorbidity, and yearly volume showed a correlation. A significant association in the in-hospital mortality was observed between low- and very-high-volume hospitals.

CONCLUSION

In this large nationwide cohort of patients with gastric cancer using an MLA, LDG was shown to be safer with lower mortality and postoperative complication rates than ODG.

Robotic-Assisted Distal Gastrectomy for Gastric Cancer Using an Oval-Shaped Port Device

INTRODUCTION

This report describes the techniques and outcomes of robot-assisted distal gastrectomy (RDG) for gastric carcinoma using an oval-shaped port device.

MATERIALS AND METHODS

A total of 15 patients underwent RDG with lymphadenectomy using the E‧Z Access/LAP-PROTECTOR oval-type device (Hakko Co., Ltd., Tokyo, Japan) performed by a single surgeon between 2018 and 2019. This device was introduced to the umbilicus under two settings, depending on the patient's figure. A horizontal setting (n=7) was used to reduce the number of trocar skin incisions in thin patients by placing a scope trocar and assist port within the E-Z Access. The vertical setting (n=8) was used for large and obese patients, enabling the endoscope position to move 50mm toward the cephalad side by rotating the device 180° to improve the surgical view of the suprapancreatic area ("dual port position" using the E‧Z Access oval-type device). The intracorporeal Billroth-I anastomosis or Roux-en-Y method was used for reconstruction. The short-term patient outcomes were determined to assess the safety and feasibility of our procedures.

RESULTS

The E-Z Access oval-type device was useful for maintaining an optimal surgical field and reducing the number of skin incisions and the level of surgeon stress. Furthermore, its removal cap and wound protector allowed for an airtight seal, umbilical wound protection, and smooth specimen removal and re-pneumoperitoneum. R0 resection was accomplished in all cases without the need for conversion to open or conventional laparoscopic surgery. The median operating time was 323 (range, 245-590) minutes, and the median blood loss was 5ml. The median number of retrieved lymph nodes was 30. Neither major postoperative complication, including umbilical skin damage, nor postoperative mortality, was observed. The mean length of the hospitalization was 12.5 days.

CONCLUSIONS

Our robotic approach using an oval-shaped port device for gastric cancer patients is feasible in terms of patient safety and curability.

Preoperative factors predicting the need for additional ports during single-incision laparoscopic cholecystectomy

INTRODUCTION

Single-incision laparoscopic cholecystectomy (SILC) is gaining popularity as a minimally invasive technique that provides some benefits in terms of improved cosmesis. However, the insertion of an additional port is required in a subset of cases.

METHODS

We retrospectively analyzed 308 SILC procedures in patients with benign gallbladder diseases, except acute cholecystitis, to identify preoperative factors predicting the need for an additional port.

RESULTS

SILC was completed with a single incision in 272 patients (88%); the insertion of at least one additional port was required in 36 patients (12%). The additional port requirement was associated with a longer operative time (P < 0.0001), greater intraoperative blood loss (P < 0.0001), and longer postoperative hospital stay (P = 0.0002). Multivariate analysis revealed male gender (odds ratio: 2.57, P = 0.0170), prior history of upper abdominal surgery (odds ratio: 5.53, P = 0.0132), and a higher preoperative white blood cell count (odds ratio: 3.62, P = 0.0244) to be independent factors associated with the requirement for an additional port.

CONCLUSION

Our results suggest that gender, prior history of upper abdominal surgery, and white blood cell count can predict the likelihood of requiring an additional port in SILC.

Reduced Port Distal Gastrectomy With a Multichannel Port Plus One Puncture (POP)

BACKGROUND

This report describes the techniques and outcomes of reduced port distal gastrectomy (RPDG) with a multichannel port plus one puncture (POP) for gastric cancer patients.

PATIENTS AND METHODS

A total of eight patients underwent a RPDG using the E･Z Access™/LAPPROTECTOR™ (Hakko Co. Ltd., Tokyo, Japan) oval type devices with POP by a single surgeon. The median age of the patients was 66 years (range 48-75 years), and their median BMI was 22.3 kg/m2 (range 17.7-26.8 kg/m2). One (12.5 %) of eight patients was female. A thin caliber trocar MiniPort™ (Covidien, New Haven, CT) was inserted at the left upper quadrant by puncture without incision. An assistant used Endo Relief™ (Hope Denshi Co. Ltd., Chiba, Japan) needlescopic forceps. In three cases, the pre-bent forceps (KTY-I, Adachi Industry Co. Ltd., Gifu, Japan) was introduced for surgeon's left hand. After the liver was retracted with a 2-0 Prolene suture, a distal subtotal resection of the stomach with D1+ or D2 lymph node dissection was performed. The Roux-en-Y method or Billroth-I anastomosis was used for reconstruction. The short-term patient outcomes were investigated to evaluate the feasibility of RPDG with POP.

RESULTS

We employed this technique without the use of additional trocars in every patient except one. No conversion to laparotomy was observed. Both the Endo Relief™ forceps and prebent forceps were useful to maintain countertraction and keep triangulation. The median length of the operation was 374 (range, 268-420) minutes, and the median estimated blood loss was 45 (range, 5-180) ml. The median number of dissected lymph nodes was 32 (range 22-46). Neither major postoperative complications, such as anastomotic leakage and stricture, nor postoperative mortality were observed. The mean length of the hospital stay was 1,5 days. The umbilical wound was indistinct.

CONCLUSION

RPDG with POP using a needlescopic device procedure is feasible in terms of patient safety and curability.

Single-incision laparoscopic cholecystectomy for acute cholecystitis: A retrospective cohort study of 52 consecutive patients

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) has become increasingly popular but its role in acute cholecystitis remains controversial.

METHODS

We compared the clinical features and outcomes of SILC procedures between 52 patients with acute cholecystitis (the AC group) and 308 patients without acute cholecystitis (the NAC group). We also analyzed clinical variables to identify factors affecting difficulties associated with SILC for acute cholecystitis.

RESULTS

The patients in the AC group were significantly older than those in the NAC group (72 vs. 61 years, median, P = 0.0005). The preoperative levels of white blood cell counts were significantly higher in the AC group than in the NAC group (6600 vs. 5500/μL, P = 0.0004). The operative time was significantly longer in the AC group than in the NAC group (188 vs. 135 min, P < 0.0001). The volume of intraoperative blood loss was significantly larger in the AC group than in the NAC group (20 vs. 5 mL, P < 0.001). Furthermore, additional trocar insertion was required in 12% in the NAC group, whereas it was required in 60% in the AC group (P < 0.0001). Regarding the difficulties of SILC for acute cholecystitis, delayed operation (after 72 h from the onset) was significantly associated with a prolonged operative time, while a higher grade of acute cholecystitis (grade II or III) was significantly associated with an increased blood loss during surgery.

CONCLUSIONS

These findings suggest that when compared to SILC for gallbladder diseases without acute inflammation, SILC for acute cholecystitis was associated with a longer operative time, increased blood loss, higher rate of additional trocar requirement, higher rate of postoperative complications, and longer hospital stay. The difficulties associated with SILC for acute cholecystitis were affected by the timing of surgery and the grade of inflammation.

Rare combination of familial adenomatous polyposis and gallbladder polyps

Familial adenomatous polyposis is associated with a high incidence of malignancies in the upper gastrointestinal tract (particularly ampullary adenocarcinomas). However, few reports have described a correlation between familial adenomatous polyposis and gallbladder neoplasms. We present a case of a 60-year-old woman with familial adenomatous polyposis who presented with an elevated mass in the neck of the gallbladder (measuring 16 mm × 8 mm in diameter) and multiple small cholecystic polyps. She had undergone a total colectomy for ascending colon cancer associated with familial adenomatous polyposis 22 years previously. The patient underwent laparoscopic cholecystectomy under a preoperative diagnosis of multifocal gallbladder polyps. Pathologic examination of the resected gallbladder revealed more than 70 adenomatous lesions, a feature consistent with adenoma of the gallbladder. This case suggests a requirement for long-term surveillance of the biliary system in addition to the gastrointestinal tract in patients with familial adenomatous polyposis.

Mitochondrial transcription factor a worsens the clinical course of patients with pancreatic cancer through inhibition of apoptosis of cancer cells

OBJECTIVE

Mitochondrial transcription factor A (mtTFA) is mandatory for both the transcription and maintenance of mitochondrial DNA. This study aimed to investigate the significance of mtTFA expression in pancreatic ductal adenocarcinoma (PDAC).

METHODS

Surgical specimens from 93 patients with PDAC who all underwent pancreatectomy were immunohistochemically stained using a polyclonal anti-mtTFA antibody. The relationship between the expression of mtTFA, clinicopathologic factors, and prognosis of these patients were evaluated.

RESULTS

Positive mtTFA expression was significantly associated with lymphovascular invasion and metastatic recurrence in the liver and correlated with an advanced surgical stage. A univariate analysis showed that the patients with positive mtTFA expression had a significantly shorter survival time than those patients with negative mtTFA expression, and a multivariate analysis revealed that mtTFA expression was one of the independent prognostic factors in patients with PDAC. Positive mtTFA expression was significantly correlated with a low apoptotic index but not significantly correlated with the mind bomb homolog-1 (MIB-1) index.

CONCLUSIONS

The expression mtTFA worsens the clinical course of patients with PDAC through the inhibition of apoptosis of PDAC cells and is an independent marker for the poor prognosis of the patients with PDAC after pancreatectomy. Mitochondrial transcription factor A may be a novel target for the treatment of PDAC.

Rapid postoperative reduction in prognostic nutrition index is associated with the development of pancreatic fistula following distal pancreatectomy

BACKGROUNDS

Despite recent advances in surgical techniques and devices for pancreatic remnant closure, postoperative pancreatic fistula (POPF) still remains one of the common complications after distal pancreatectomy (DP). Identification of risk factors for POPF may lead to the development of new strategies to prevent this ominous complication.

METHODS

We retrospectively reviewed data on 44 patients undergoing DP with the use of a stapler to identify risk factors for POPF. Study variables included preoperative prognostic nutritional index (PNI) and reduction rate of PNI on postoperative day (POD) 7.

RESULTS

POPF occurred in 23 patients (52%), of which 13 (56%) were grade B or C. Univariate analyses comparing patients with POPF and those without POPF showed significant differences in body mass index (P = 0.0102), pancreatic thickness (P = 0.0134), white blood cell count on POD7 (P = 0.0432), C-reactive protein level on POD7 (P = 0.0123), and PNI reduction rate (P = 0.0471). A multivariate analysis revealed pancreatic thickness (P = 0.0121) and PNI reduction rate (P = 0.0165) to be significant factors for POPF. Furthermore, the PNI reduction rate was significantly higher in patients with clinically relevant (grade B/C) POPF than in those with no or grade A POPF (P = 0.0257). In most patients, the massive postoperative PNI reduction preceded the diagnosis of clinically relevant POPF.

CONCLUSIONS

These findings suggest that rapid postoperative reduction in PNI is associated with the development of POPF.

Risk factors for a prolonged operative time in a single-incision laparoscopic cholecystectomy

BACKGROUND

A prolonged operative time is associated with adverse post-operative outcomes in laparoscopic surgery. Although a single-incision laparoscopic cholecystectomy (SILC) requires a longer operative time as compared with a conventional laparoscopic cholecystectomy, risk factors for a prolonged operative time in SILC remain unknown.

METHODS

A total of 20 clinical variables were retrospectively reviewed to identify factors for a prolonged operative time (longer than 3 h) in a total of 220 consecutive patients undergoing SILC.

RESULTS

The median operative time was 145 min (range, 55-435) and a prolonged operative time was required in 62 patients (28%). Independent factors that predict a prolonged operative time as identified through multivariate analysis were body mass index (BMI) (P = 0.009), acute cholecystitis (P < 0.001) and operator (resident or staff surgeon) (P < 0.001). Furthermore, a prolonged operative time was significantly associated with an increased amount of intra-operative blood loss (P < 0.001) and a prolonged stay after surgery (P < 0.001).

CONCLUSIONS

These findings suggest that a higher BMI, acute cholecystitis and a resident as an operator significantly increase the duration of SILC procedures.

Pancreatic somatostatinoma diagnosed preoperatively: report of a case

CONTEXT

Somatostatinoma is a rare neoplasm of the pancreas. Preoperative diagnosis is often difficult.

CASE REPORT

We report a 72-year-old woman with a pancreatic head tumor measuring 37 mm in diameter, and enlargement of the lymph nodes on the anterior surface of the pancreatic head and the posterior surface of the horizontal part of the duodenum. Laboratory data showed an elevated plasma somatostatin concentration. Examination of a biopsy specimen of the pancreatic head mass obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) showed histopathological features of a neuroendocrine tumor. Immunohistochemical staining showed that the tumor cells were positive for somatostatin, leading to a preoperative diagnosis of pancreatic somatostatinoma. The patient underwent pylorus-preserving pancreaticoduodenectomy. The plasma somatostatin concentration decreased progressively after surgery.

CONCLUSIONS

A rare case of pancreatic somatostatinoma with lymph node metastases was presented. Immunohistochemical analysis of a biopsy specimen obtained by EUS-FNA was useful for preoperative diagnosis.

Intermittent negative pressure external drainage of the pancreatic duct reduces the incidence of postoperative pancreatic fistula after pancreaticojejunostomy

BACKGROUND/AIMS

The formation of a pancreatic fistula remains one of the serious morbidities after pancreaticojejunostomy. This study is focused on the efficacy of negative pressure external drainage of the main pancreatic duct in pancreaticojejunostomy.

METHODOLOGY

Fifty-eight consecutive patients who underwent pancreaticojejunostomy at our hospital from May 2008 to May 2012 were enrolled in this study. They were divided into a group of 25 earlier patients (Group A) with gravity drainage of the pancreatic duct (from May 2008 until May 2010) and a group of 33 later patients (Group B) with negative pressure drainage (treated from June 2010 until May 2012). These two groups were compared based on the patient characteristics, parameters related to the operation, and postoperative complications and hospital stay. Furthermore, examinations were performed for subgroups of patients with a soft pancreas (43 patients) or a hard pancreas (15 patients) based on the hardness of the remnant pancreas.

RESULTS

There were no statistically significant differences between the two groups in the patient demographics, laboratory data or parameters related to the operation. Although there was no difference in the amount of drainage from the pancreaticojejunostomy, the amylase values in the drainage around the pancreaticojejunostomy of group B were significantly lower than those of group A (p = 0.026). The complication rates were also significantly lower in group B than in group A for the development of a postoperative pancreatic fistula (POPF) (p = 0.012), intraabdominal abscess (p = 0.045), or wound infection (p = 0.01). There were no statistically significant differences between the two groups in the mean hospital stay. When restricted to patients with a soft pancreas, the incidence of POPF (grade B or C) of group B was significantly lower than that of group A (p = 0.003). The P-value for the soft pancreas group was lower than that of the overall cases. In the examination restricted to patients with a hard pancreas, POPF (grade B or C) did not occur in either group.

CONCLUSIONS

This retrospective study showed that the application of intermittent negative pressure external drainage of the main pancreatic duct significantly reduces the rate of pancreatic fistula and intra-abdominal abscess formation after pancreaticojejunostomy, and these effects were more remarkable in the patients with a soft pancreas.

A newly developed oval-shaped port device (E•Z ACCESS Oval type) for use in reduced port surgery: initial clinical experiences with cholecystectomy

We recently developed an oval-shaped E•Z Access device designed exclusively for use with the LAP PROTECTOR™ Oval type device (Hakko Co. Ltd., Tokyo, Japan). The transverse abdominal opening diameter made by round-shaped (Alexis® Wound Retractor, Applied Medical, Rancho Santa Margarita, CA; and LAP PROTECTOR™ Round type) and oval-shaped (LAP PROTECTOR™ Oval type) wound retractors was measured and compared in 5 patients with cholecystolithiasis. Each device was placed through a single 25-mm longitudinal umbilical incision, and the length of trocar separation was compared. LESS cholecystectomy was then performed using the oval-shaped E•Z ACCESS/LAP PROTECTOR™. The transverse abdominal opening diameter was maximized with the LAP PROTECTOR™ Oval type device. The average distance between the working-ports for the glove method, round-shaped, and oval-shaped E•Z ACCESS/LAP PROTECTOR™ devices in the 25-mm umbilical incisions were 20 ± 0.8 mm, 24 ± 1.5 mm, and 35 ± 0.8 mm, respectively. Wider trocar separation was achieved using the oval-shaped device, making the surgical procedures easier to perform. No perioperative port-related or surgical complications were observed. LESS cholecystectomy using the E•Z ACCESS Oval type device was found to be technically feasible. The Oval type device appears to allow for wider trocar separation, thereby reducing stress on the surgeon, ensuring patient safety, and providing cosmetic benefits.

Routine intraoperative cholangiography during single-incision laparoscopic cholecystectomy: a review of 196 consecutive patients

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) has been increasingly performed as a potentially less invasive alternative to standard laparoscopic cholecystectomy. However, recent evidences suggest a higher incidence of complications, notably bile duct injuries, in SILC. We reviewed our experiences with routine intraoperative cholangiography (IOC) during SILC to investigate its feasibility and usefulness.

METHODS

Among 228 patients who underwent SILC at our institution from September 2009 to July 2012, a total of 196 patients in which an IOC was attempted were retrospectively reviewed.

RESULTS

IOC was successful in 178 of 196 patients, yielding a success rate of 90.8 %. There were no IOC-related complications. Common bile duct (CBD) stones were detected by IOC in 16 patients (8.2 %), all of which were treated by subsequent single-incision laparoscopic CBD exploration or postoperative endoscopic retrograde cholangiopancreatography with stone extraction. In addition, IOC revealed filling defects in the cystic duct (four patients) and poor passage of contrast medium into the duodenum (one patient). In one patient with severe acute cholecystitis, cholangiography via an endoscopic nasobiliary drainage tube revealed misinterpretation of CBD as cystic duct.

CONCLUSIONS

We, thus, conclude that routine IOC during SILC is feasible and useful to detect biliary stones and to gain an accurate picture of biliary anatomy.

Laparoendoscopic single-site common bile duct exploration using the manual manipulator

BACKGROUND

Laparoendoscopic single-site (LESS) surgery has developed as a new surgical modality that has increased cosmetic benefits over conventional endoscopic surgery. However, there are no reports about LESS surgery in common bile duct exploration. This report presents a LESS surgery to manage CBD stones by laparoscopic choledochotomy and C-tube placement with favorable outcomes.

METHODS

This retrospective review analyzes 13 patients who underwent LESS CBD exploration with C-tube drainage for choledocholithiasis. The technique is herein described and the outcomes measured. The Radius Surgical System (Tübingen Scientific Medical, Tübingen, Germany) is a flexible manual manipulator that was applied for suturing and ligation to overcome the difficulties associated with LESS surgery.

RESULTS

The diameters of the CBDs ranged from 12 to 20 mm, the median number of stones was 5.8, and the median diameter of stones was 9 mm. All of the routine procedures including choledochotomy, intraoperative ultrasound, choledochoscopy, and intraoperative cholangiography guidance were performed. Stone clearance from the CBD was achieved for all but one of the patients. It was possible to close the common bile duct opening with regular forceps, but this required extra effort compared to conventional laparoscopic surgery. On the other hand, the manual manipulator enabled the optimal penetration angle and was useful for both intracorporeal suturing and ligation for the closure of the common bile duct opening. The manual manipulator also helped to overcome in-line viewing and hand/instruments collisions, which are common problems in LESS surgery. No mortality was associated with this procedure, and two wound infections were drained without anesthesia. No recurrent stones were observed during the follow-up period.

CONCLUSIONS

LESS surgery was successfully applied to CBD exploration as an available alternative to conventional laparoscopic surgery. This method is technically feasible and produces superior cosmetic results. The manual manipulator may therefore have several advantages for performing LESS surgery.

Efficacy of micafungin in empirical therapy of deep mycosis in surgically ill patients

Micafungin (MCFG), an echinocandin antifungal agent, exhibits antifungal activity against Candida albicans and non-albicans Candida. The fungicidal activity of MCFG against clinical isolates of Candida species was investigated, and the clinical efficacy of MCFG in therapy of deep mycosis in surgery was studied using the AKOTT algorithm. The minimum inhibitory concentration and minimum fungicidal concentration values of fluconazole were ≤0.06-4 and >64 μg/ml, respectively, for each strain, whereas these values of MCFG were 0.008-0.5 and 0.016-1 μg/ml, suggesting that MCFG provided superior fungicidal ability against Candida albicans and non-albicans Candida. The subjects were separated into two groups: group A consisted of 20 subjects with both persisting fever refractory to broad-spectrum antibiotics and positive reaction to β-D-glucan test, and group B consisted of 20 subjects with either of those conditions. The overall response was evaluated as "effective" in 17 patients (85%) and 20 patients (100%) in groups A and B, respectively. In total, response was evaluated as "effective" in 37 patients (92.5%) and "ineffective" in 3 patients (7.5%). These findings suggest that MCFG administration should be used as empirical therapy for deep mycosis in surgically ill patients as it was shown to be an effective antifungal drug lacking serious adverse effects.

Enucleation of an Insulinoma of the Pancreas Using Reduced Port Surgery: Report of a Case

Reduced port surgery (RPS) is a new surgical modality producing increased cosmetic benefits over conventional endoscopic surgery. We herein report the first case of insulinoma of the pancreas treated by RPS. RPS enucleation was performed for a 23-year-old Japanese female who was admitted to our hospital with repeated episodes of hypoglycemia attributable to an insulinoma. The preoperative examinations confirmed the diagnosis of a solitary insulinoma of the pancreatic tail. Enucleation of the insulinoma using RPS was performed. A 2.5-cm umbilical incision was made, and three laparoscopic trocars were individually inserted into the abdominal cavity via this incision. Another 3-mm trocar was inserted from the left subcostal region. All procedures that were usually performed in conventional laparoscopic surgery were also performed by RPS: intraoperative ultrasonography, mobilization of the tail of the pancreas, enucleation of the tumor, and suturing of the stump. A mechanical manipulator, the Radius Surgical System (Radius), was used for suturing and ligation. The Radius was sufficient to overcome in-line viewing and hand/instrument collisions, and enabled us to perform precise suturing and ligation. Serial blood sugar, C-peptide immunoreactivity (CPR), and immunoreactive insulin (IRI) measurements revealed that all values were normal after resection. The patient had an uneventful postoperative course. RPS was successfully applied for enucleation of a solitary mass in the tail of the pancreas, and represents an alternative to conventional laparoscopic surgery. This method is technically feasible and results in superior cosmesis. The Radius facilitated advanced laparoscopic surgery and may also have advantages in RPS.

Disk suspension method: a novel and safe technique for the retraction of the liver during laparoscopic surgery (with video)

BACKGROUND

A good operative field is important for safe operations, but it is sometimes difficult to obtain a satisfactory operative field in laparoscopic upper abdominal surgery. We developed a novel and safe technique for the retraction of the liver and falciform ligament during laparoscopic surgery, and evaluated its technical feasibility and safety.

METHODS

Forty-three patients with gastric cancer were divided into two groups: disk suspension group (DS group; snake retractor and elastic band fixation with a silicon disk), and fixed retractor group (FR group; snake retractor and nonelastic band fixation without a silicon disk). To evaluate liver damage during retraction, we measured the aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels preoperatively and on postoperative day (POD) 1.

RESULTS

In the DS group, all liver lobes were adequately retracted and the hepatoduodenal and gastrohepatic ligaments were fully exposed. This procedure took less than 3 min. On the other hand, 5 of 18 patients of the FR group had insufficient surgical fields for laparoscopic gastrectomy because of soft and/or large livers. Although the preoperative AST and ALT levels were not different between the two groups, the DS group did not display increases in both AST and ALT levels, whereas the FR group showed increases in both on POD 1 (AST: 50.2 ± 8.4 IU/l vs. 124.2 ± 37.7 IU/l, P = 0.07; and ALT: 35.6 ± 6.4 IU/l vs. 106.1 ± 36.2 IU/l, P = 0.07). No complications related to the liver retraction were observed in the DS group. However, liver congestion was evident in six patients and minor liver injury in two patients of the FR group during the esophagojejunostomy.

CONCLUSIONS

The DS method is a simple and safe and provides a better surgical field during laparoscopic surgery of the upper abdomen without damaging the liver.

Reticulon 4B (Nogo-B) is a novel regulator of hepatic fibrosis

Nogo-B, also known as Reticulon 4B, plays important roles in vascular injuries. Its function in the liver is not understood. The aim of this study was to characterize Nogo-B in liver fibrosis and cirrhosis. Nogo-B distribution was assessed in normal and cirrhotic human liver sections. We also determined the levels of liver fibrosis in wild-type (WT) and Nogo-A/B knockout (NGB KO) mice after sham operation or bile duct ligation (BDL). To investigate the mechanisms of Nogo-B's involvement in fibrosis, hepatic stellate cells were isolated from WT and NGB KO mice and transformed into myofibroblasts. Portal pressure was measured to test whether Nogo-B gene deletion could ameliorate portal hypertension. In normal livers, Nogo-B expression was found in nonparenchymal cells, whereas its expression in hepatocytes was minimal. Nogo-B staining was significantly elevated in cirrhotic livers. Fibrosis was significantly increased in WT mice 4 weeks after BDL compared with NGB KO mice. The absence of Nogo-B significantly reduced phosphorylation of Smad2 levels upon transforming growth factor β (TGF-β) stimulation. Reconstitution of the Nogo-B gene into NGB KO fibroblasts restored Smad2 phosphorylation. Four weeks after BDL, portal pressure was significantly increased in WT mice by 47%, compared with sham-operated controls (P = 0.03), whereas such an increase in portal pressure was not observed in NGB KO mice (P = NS).

CONCLUSION

Nogo-B regulates liver fibrosis, at least in part, by facilitating the TGFβ/Smad2 signaling pathway in myofibroblasts. Because absence of Nogo-B ameliorates liver fibrosis and portal hypertension, Nogo-B blockade may be a potential therapeutic target in fibrosis/cirrhosis.

The type III inositol 1,4,5-trisphosphate receptor is associated with aggressiveness of colorectal carcinoma

The inositol 1,4,5-trisphosphate receptor (InsP3R) mediates Ca(2+) signaling in epithelia and regulates cellular functions such as secretion, apoptosis and cell proliferation. Loss of one or more InsP3R isoform has been implicated in disease processes such as cholestasis. Here we examined whether gain of expression of InsP3R isoforms also may be associated with development of disease. Expression of all three InsP3R isoforms was evaluated in tissue from colorectal carcinomas surgically resected from 116 patients. Type I and II InsP3Rs were seen in both normal colorectal mucosa and colorectal cancer, while type III InsP3R was observed only in colorectal cancer. Type III InsP3R expression in the advancing margins of tumors correlated with depth of invasion, lymph node metastasis, liver metastasis, and TNM stage. Heavier expression of type III InsP3R also was associated with decreased 5-year survival. shRNA knockdown of type III InsP3R in CACO-2 colon cancer cells enhanced apoptosis, while over-expression of the receptor decreased apoptosis. Thus, type III InsP3R becomes expressed in colon cancer, and its expression level is directly related to aggressiveness of the tumor, which may reflect inhibition of apoptosis by the receptor. These findings suggest a previously unrecognized role for Ca(2+) signaling via this InsP3R isoform in colon cancer.

Case report: laparoendoscopic single-site fenestration of giant hepatic cyst

Laparoendoscopic single-site (LESS) surgery has developed as a new surgical modality producing increased cosmetic benefits over conventional endoscopic surgery. However, there are limited reports about LESS surgery in liver diseases. We reported a case of a giant hapatic cyst that was treated by LESS surgery. LESS fenestration was performed on a 60-year-old female. A 2.2-cm umbilical incision was made. Three laparoscopic trocars were individually inserted into the abdominal cavity via a single umbilical incision. Only straight laparoscopic instruments were applied throughout the procedures. Aspiration, dome resection, argon laser coagulation, drainage, and removal were performed by LESS surgery. One of the 5-mm trocars was replaced with a 12-mm trocar to retrieve the resected cyst wall. All of the procedures for liver fenestration were the same as conventional laparoscopy and were successfully performed without any difficulties. The patient had an uncomplicated postoperative course. The LESS surgery has been successfully applied to liver fenestration as an available alternative to conventional laparoscopic fenestration. This method is technically feasible and results in superior cosmesis.

Chemopreventive effect of 4-[3,5-Bis(trimethylsilyl) benzamido] benzoic acid (TAC-101) on MNU-induced colon carcinogenesis in a rat model

PURPOSE

4-[3,5-Bis(trimethylsilyl)benzamido] benzoic acid (TAC-101) is a novel retinobenzoic acid derivative. The chemopreventive effect and the mechanism of action of TAC-101 were investigated using a rat chemical colon carcinogenesis model.

MATERIALS AND METHODS

Colon tumors were induced using intra-rectal instillation of N-methyl-N-nitrosourea (MNU) in F344 rats. These rats were divided into five groups, control, high dose (TAC-101 8 mg/kg)-long period (four weeks), high dose-short period (one week), low dose (TAC-101 0.8 mg/kg)-long period and low dose-short period. After the large bowels were resected at 20 weeks, the number of aberrant crypt foci (ACF) and tumors in the colon were counted. Proliferating cell nuclear antigen (PCNA) positive index, apoptotic index (AI) and Fas expression were also evaluated using immunohistochemistry.

RESULTS

The tumor incidence and the tumor number in the high dose-long period group were decreased in comparison to those in the other groups, but not significantly. However, the number of ACF or PCNA positive indices in the high dose-long period group was significantly decreased in comparison to that in the other groups. On the other hand, the AI and the Fas expression pattern in the tumor and the normal appearing mucosa were not changed in any of the groups.

CONCLUSION

TAC-101 might inhibit MNU induced colon carcinogenesis via a decrease of ACF. The mechanism of this chemoprevention may be related to a reduction in cell proliferation, but is not directly associated with apoptosis.

Prognostic significance of the local expression of interleukin-12 in patients with advanced gastric cancer

BACKGROUND

Interleukin (IL)-12 is a heterodimeric cytokine that exhibits potent antitumor and antimetastatic activities. Very few studies have so far investigated the local expression of L-12 in tumor specimens of gastric cancer. The purpose of this study was to investigate the immunohistochemical expression of IL-12 in patients with gastric cancer.

PATIENTS AND METHODS

IL-12 was immunohistochemically stained using monoclonal antihuman IL-12 antibody (1-1A4) in surgical specimens of 117 gastric cancer patients. The IL-12-positive cell density was calculated. The relationships among the IL-12-positive cell density, clinicopathological factors and 5-year survival rate were evaluated.

RESULTS

Among the patients (n=117), the 5-year survival rate after surgery was not statistically different between the patients with high and low IL-12 positive cell-density. However, in the patients with advanced gastric cancer (n=85), those with a high IL-12-positive cell density showed a significantly better prognosis in comparison with those with a low IL-12-positive cell density (p=0.0104). A multivariate analysis indicated that the IL-12-positive cell density and TNM stage are significant prognostic factors.

CONCLUSION

IL-12-positive cell density may be a significant independent prognostic factor in surgical specimens of advanced gastric cancer.

Cyclic AMP regulates bicarbonate secretion in cholangiocytes through release of ATP into bile

BACKGROUND & AIMS

Bicarbonate secretion is a primary function of cholangiocytes. Either adenosine 3',5'-cyclic monophosphate (cAMP) or cytosolic Ca(2+) can mediate bicarbonate secretion, but these are thought to act through separate pathways. We examined the role of the inositol 1,4,5-trisphosphate receptor (InsP3R) in mediating bicarbonate secretion because this is the only intracellular Ca(2+) release channel in cholangiocytes.

METHODS

Intrahepatic bile duct units (IBDUs) were microdissected from rat liver then luminal pH was examined by confocal microscopy during IBDU microperfusion. Cyclic AMP was increased using forskolin or secretin, and Ca(2+) was increased using acetylcholine (ACh) or adenosine triphosphate (ATP). Apyrase was used to hydrolyze extracellular ATP, and suramin was used to block apical P2Y ATP receptors. In selected experiments, IBDUs were pretreated with short interfering RNA (siRNA) to silence expression of specific InsP3R isoforms.

RESULTS

Both cAMP and Ca(2+) agonists increased luminal pH. The effect of ACh on luminal pH was reduced by siRNA for basolateral (types I and II) but not apical (type III) InsP3R isoforms. The effect of forskolin on luminal pH was reduced by a cystic fibrosis transmembrane conductance regulator (CFTR) inhibitor and by siRNA for the type III InsP3R. Luminal apyrase or suramin blocked the effects of forskolin but not ACh on luminal pH.

CONCLUSIONS

Cyclic AMP-induced ductular bicarbonate secretion depends on an autocrine signaling pathway that involves CFTR, apical release of ATP, stimulation of apical nucleotide receptors, and then activation of apical, type III InsP3Rs. The primary role of CFTR in bile duct secretion may be to regulate secretion of ATP rather than to secrete chloride and/or bicarbonate.

4- [3,5-bis(trimethylsilyl)benzamido] benzoic acid (TAC-101) induced fas expression and activated caspase-3 and -8 in a DLD-1 colon cancer cell line

BACKGROUND

4-[3,5-Bis (trimethylsilyl) benzamido] benzoic acid (TAC-101) is a novel retinobenzoic acid derivative which has a specific binding affinity to the retinoic acid receptors (RAR)alpha and RARbeta. Using time-dependent FACScan analysis, it was observed that TAC-101 induced apoptosis in a DLD-1 human colon cancer cell line. In this study, the induction of apoptosis-related proteins and the activities of caspases in a DLD-1 cell line under medication with TAC-101 were investigated.

MATERIALS AND METHODS

DLD-1 cells were cultured with different concentrations of TAC-101 for 12, 24 and 48 h. The expressions of Fas, TNF-R1, DR3, bcl-2, Bax and Bid were measured using a Western blot analysis. The activities of caspase-3, -8 and -9 were measured using a colorimetric protease assay kit.

RESULTS

The Western blot analysis showed that TAC-IO1 had almost no effect on the level of Bcl-2, Bax or Bid protein. Although TAC-101 did not change the expression of TNF-R1 and DR3, TAC-101 increased the expression of Fas in both a time- and a dose-dependent manner. A 3-fold increase in caspase-3 activity and a 1.5-fold increase in caspase-8 activity were observed in cells treated with TAC-101 in comparison to the control cells (p<0.01).

CONCLUSION

Our data indicate that the death receptor root of the apoptotic signal transduction in DLD-1 cells mainly participates in the apoptotic induction of TAC-101. Because the compounds inducing apoptotic activity are frequent targets of cancer therapy, TAC-101 may be a good candidate for use in the treatment of colon cancer.

Lymphatic microvessel density is an independent prognostic factor in colorectal cancer

PURPOSE

Although lymph node metastasis via lymphatic vessels often is related with an adverse outcome, it is not well known whether lymphatic spread to lymph node needs the development of the new lymphatic formation. In addition, the correlation between lymphangiogenesis and prognosis has not been well documented. This study was designed to assess the prognostic value of lymphangiogenesis and lymphatic vessel invasion in colorectal cancer.

METHODS

We examined 106 colorectal cancer specimens by immunostaining for podoplanin, lymphatic endothelial specific marker. We evaluated lymphangiogenesis, as measured by lymphatic microvessel density, and lymphatic vessel invasion. We next investigated the association of these two parameters with the clinicopathologic findings and prognosis.

RESULTS

A significant correlation was observed between high lymphatic microvessel density and positive lymphatic vessel invasion (P = 0.0003). Positive lymphatic vessel invasion was significantly associated with the presence of lymph node metastasis (P = 0.0071). The survival curves demonstrated that both high lymphatic microvessel density and positive lymphatic vessel invasion were correlated with an adverse outcome (P = 0.0004 and P = 0.009, respectively). In a univariate analysis, high lymphatic microvessel density and positive lymphatic vessel invasion were negatively associated with the overall survival (P = 0.0011 and P = 0.0118, respectively). Furthermore, high lymphatic microvessel density, but not lymphatic vessel invasion, correlated with a poor outcome in a multivariate analysis (P = 0.0114).

CONCLUSIONS

Our data suggested that lymphatic vessel invasion was related with lymph node metastasis and that both lymphatic microvessel density and lymphatic vessel invasion were related with an adverse outcome in colorectal cancer. Furthermore, lymphatic microvessel density may be a useful prognostic factor in colorectal cancer.

Significance of lymphangiogenesis as assessed by immunohistochemistry for podoplanin in patients with esophageal carcinoma

BACKGROUND

Although lymph node involvement is an important prognostic factor for survival in patients with esophageal carcinoma, little is known about lymphangiogenesis in esophageal carcinoma. Podoplanin, a mutin-type transmembrane glycoprotein, specifically recognizes the lymphatic endothelium and is used as a lymphatic-specific marker. Anti-human podoplanin antibody was therefore used to quantify and evaluate the lymphangiogenesis in esophageal carcinoma.

PATIENTS AND METHODS

Lymphatic endothelial cells were detected by immunohistochemistry using mouse monoclonal anti-human podoplanin antibody. The relationship between lymphatic microvessel density (LMVD) and lymphatic vessel invasion (LVI), clinicopathological factors and the prognosis in 29 patients with esophageal carcinoma was investigated.

RESULTS

LMVD was significantly higher in esophageal carcinoma patients who had any of the following characteristics: T3-T4 (p=0.0370), tumors more advanced than stage III (TNM staging) (p=0.0351), lymphatic invasion (p=0.0095) and LVI (+) (p=0.0016). LVI significantly correlated with lymph node metastasis (p=0.0003), TNM staging (p=0.0182) and LMVD (p=0.0388). The survival rate of patients with a low LMVD tended to be higher than that of patients with a high LMVD (5-year survival rate, 62.5% vs. 29.4%, p=0.0832).

CONCLUSION

The evaluation of lymphangiogenesis using podoplanin immunohistochemistry may be useful in predicting lymph node metastasis and the prognosis in patients with esophageal carcinoma.

Correlation between the urinary dihydrouracil-uracil ratio and the 5-FU plasma concentration in patients treated with oral 5-FU analogs

BACKGROUND

The determination of dihydropyrimidine dehydrogenase (DPD) deficiency is important in avoiding severe 5-fluorouracil (FU) toxicity. The dihydrouracil (UH2)-uracil (Ura) ratio (UH2/Ura) in plasma might be an important indicator of the risk of 5-FU catabolic deficiency. In order to clarify this possibility, the pyrimidine metabolites and the UH2/Ura were measured in urine and the plasma level of 5-FU was evaluated in patients with gastric and colorectal cancer.

PATIENTS AND METHODS

Patients with primary gastric (n=14) and colorectal (n=8) cancer who had undergone surgery were recruited in this study. These patients were divided into the S-1 treatment group, which drug is a novel oral formulation of tegafur, oxonic acid and 5-chloro-2, 4-dihydroxypyridine (CDHP) (n=14) and a group receiving other drugs which include UFT (Uracil/Tegafur) or oral doxifluridine (n=8). The urinary levels of UH2 and Ura were measured by high-performance liquid chromatography (HPLC) using column swiching. The plasma level of 5-FU was assessed by gas chromatography-mass spectrometry (GC-MS).

RESULTS

The UH2/Ura or UH2/Ura (treated/no treated) in the S-1 group significantly decreased in comparison to that in the other-drug group and the plasma 5-FU concentration in the S-1 group significantly increased compared to that in the group treated with other drugs. The plasma 5-FU concentration levels significantly indicated a positive correlation with urinary Ura. Moreover, UH2/Ura treated with 5-FU analogs or UH2/Ura (treated/no treated) significantly showed a negative correlation with the plasma 5-FU concentration levels.

CONCLUSION

Our findings indicate that either urinary Ura, the UH2/Ura or UH2/Ura (treated/no treated) can predict the plasma 5-FU concentration levels or DPD deficiencies.

[A case of curatively resected schirrous gastric cancer effectively treated by combined chemotherapy of weekly paclitaxel (PTX) and CDDP]

The patient was a 40-year-old woman who had unresectable advanced gastric cancer with invasion of liver and dissemination to the peritoneal wall. Neoadjuvant chemotherapy consisting of paclitaxel (PTX) and CDDP was performed. PTX (80 mg/m2), and CDDP (25 mg/m2) was administered weekly on day 1, 8 and 15 as one cycle. After four cycles of PTX/CDDP administration,invasion of liver and gastric tumor had decreased to almost normal size, and total gastrectomy was performed. After operation, the patient was treated with six courses of PTX/CDDP and survived without recurrence as of this writing. PTX/CDDP was associated with few adverse events in hospital visits, and thought to be an effective chemotherapy against advanced gastric cancer.

Expression levels of thymidine phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD) in patients with gastrointestinal cancer

BACKGROUND

Thymidine phosphorylase (TP) is a key enzyme involved in pyrimidine nucleoside metabolism. Dihydropyrimidine dehydrogenase (DPD) is the major catabolic enzyme of 5-fluorouracil (5-FU). These are important enzymes in the pyrimidine salvage pathway and are considered to be key enzymes for determining the prognosis of patients with gastrointestinal cancer. In the present study, TP and DPD were quantified and evaluated in gastric and colorectal cancer.

PATIENTS AND METHODS

In 111 cases of malignancy, including 30 gastric cancers and 81 colorectal cancers, the expression levels of both TP and DPD in fresh-frozen samples from either tumor or adjacent normal tissue were quantified using enzyme-linked immunosorbent assay (ELISA). The relationships between TP or DPD expression levels in tumor tissues or adjacent normal tissues and clinicopathological factors were evaluated.

RESULTS

The TP expression levels in gastric or colorectal tumor tissues were found to be significantly higher than those in the adjacent normal tissue. Although the DPD expression levels in gastric tumor tissue were significantly higher than those in adjacent normal tissue, the DPD expression levels in colorectal tumor tissue were nearly identical to those in the adjacent normal tissue. The DPD expression levels in gastric tumor tissues were significantly higher than those in colorectal tumor tissues. The TP expression levels correlated significantly with the DPD expression levels in tumor or adjacent normal tissues. The DPD expression levels in tumor tissues significantly correlated with those in adjacent normal tissue.

CONCLUSION

The difference in DPD expressions between gastric and colorectal cancer tissues may reflect the organ specificity of the carcinomas and a difference in chemotherapeutic sensitivity to 5-FU or its analogs. The correlation between TP and DPD expression levels suggests the existence of a common regulatory pathway.

Relationship between interleukin-12-expressing cells and antigen-presenting cells in patients with colorectal cancer

BACKGROUND

Interleukin-12 (IL-12) is a powerful cytokine that plays an important role in cell-mediated immunity. Although IL-12 is produced by antigen-presenting cells (APCs), the relationship between IL-12 expression and APCs in colorectal cancer tissue remains unknown.

PATIENTS AND METHODS

Immunohistochemical detection of APCs and IL-12 was performed in 22 colorectal cancer specimens. CD83 and CD68 were used for the markers of mature dendritic cells (DCs) and macrophages, respectively. Double staining with CD83 or CD68 and IL-12 was also performed to detect IL-12-secreting cells. CD83-, CD68- and IL-12-positive-cell densities, clinicopathological factors and survival were analyzed.

RESULTS

CD83-, CD68- or IL-12-positive-cells were stained in the tumor stroma. Double-stained CD83/IL-12- or CD68/IL-12-positive-cells were also detected in the same area. The CD83-positive-cell density was significantly higher in patients with a high IL-12-positive-cell density than those with a low IL-12-positive-cell density. The CD83-positive-cell density was significantly lower in patients with T3-T4 depth of invasion, lymph node metastasis or tumors more advanced than stage II. The IL-12-positive-cell density tended to be lower in patients with T3-T4 depth of invasion or venous invasion. Patients with high CD83- or IL-12-positive-cell density in their cancer specimens showed significantly better prognosis.

CONCLUSION

This study provides new information on the significance of mature DCs, macrophages and IL-12-secreting cells in the local environment of colorectal cancer. Survival in patients with colorectal cancer was reflected by mature DCs and/or IL-12-positive-cell density.

4-[3,5-Bis(trimethylsilyl)benzamido] benzoic acid inhibits angiogenesis in colon cancer through reduced expression of vascular endothelial growth factor

4-[3,5-bis(trimethylsilyl)benzamido] Benzoic acid (TAC-101) has potent antiproliferative, antiangiogenic, and antitumor effects in vitro and in vivo. These effects might be due to TAC-101 binding to retinoic acid receptor alpha (RAR-alpha) and interfering with the binding of activator protein-1 (AP-1) to DNA. However, little is known about the detailed mechanism of TAC-101 function. We investigated the mechanism of the antiangiogenic effect of TAC-101 using a rat hepatic metastatic model in vivo and DLD-1 human colon cancer cells in vitro. Liver metastases were induced by portal injection of RCN-9 rat colonic cancer cells into F344 rats. TAC-101 (8 mg/kg) was orally administered 5 days per week for 4 weeks and then hepatic tumors were immunohistochemically evaluated for microvessel density (MVD) and vascular endothelial growth factor (VEGF). TAC-101 significantly reduced both MVD and VEGF expression. Northern blot analysis and ELISA indicated that TAC-101 efficiently inhibited production of VEGF mRNA and protein in DLD-1 cells in a time- and dose-dependent manner. These findings suggest that TAC-101 may inhibit progression and metastasis in colon cancer by interfering with tumor production of VEGF.

4-[3,5-Bis(trimethylsilyl)benzamido] benzoic acid (TAC-101) induces apoptosis in colon cancer partially through the induction of Fas expression

BACKGROUND

4-[3,5-Bis (trimethylsilyl) benzamido] benzoic acid (TAC-101) is a novel retinobenzoic acid derivative, which has a specific binding affinity to the retinoic acid receptors (RAR)-alpha and -beta. Apoptotic induction by TAC-101 was investigated using a rat hepatic metastatic model of rat RCN-9 colon cancer cells in vivo and FACScan analysis with the DLD-1 human colon cancer cell line in vitro.

MATERIALS AND METHODS

Hepatic metastatic tumors were induced using intra-portal injection of RCN-9 cells into F344 rats in vivo. TAC-101 (8 mg/kg) was orally administered for 5 consecutive days a week for 4 weeks. Subsequently, hepatic tumors were counted after laparotomy. Apoptotic index (A.I.) in the hepatic tumors was evaluated using immunohistochemistry for single-stranded DNA. The proliferative index (P.I.), Fas and Fas ligand were also immunohistochemically evaluated. Moreover, evaluation of apoptosis by TAC-101 in vitro using FACScan analysis was performed in the DLD-1 human colon cancer cell line.

RESULTS

Oral administration of TAC-101 resulted in a significant inhibition of hepatic metastasis without weight loss of the rats. TAC-101 significantly decreased P. I. but increased A. I. in the hepatic metastatic tumors. TAC-101 did not affect the expression of Fas ligand, but obviously increased the expression of Fas in the metastatic tumors. Moreover, TAC-101 induced early apoptosis in DLD-1 cells in a time-dependent manner in vitro.

CONCLUSION

These findings suggest that TAC-101 inhibits hepatic metastasis of colon cancer and induces apoptosis partially through enhanced Fas expression.

Relationships between local and systemic expression of interleukin-12 and plasma levels of vascular endothelial growth factor in patients with gastric cancer

BACKGROUND

Interleukin 12 (IL-12) is a heterodimeric cytokine that exhibits potent anti-tumor and anti-metastatic activities. Very few studies have investigated the expression of IL-12 in patients with gastric cancer. The purpose of the present study was to evaluate the immunohistochemical expression and serum levels of IL-12, and plasma levels of vascular endothelial growth factor (VEGF) in patients with gastric cancer.

PATIENTS AND METHODS

IL-12 was immunohistochemically stained using monoclonal anti-human IL-12 antibody (1-1A4) in surgical specimens of 27 gastric cancer patients. IL-12-positive cells were counted and positive cell density was calculated. Blood was obtained before surgery. Serum levels of IL-12 and plasma levels of VEGF were assessed using the quantitative sandwich enzyme immunoassay technique. The relationships of IL-12-positive cell density, serum levels of IL-12, plasma levels of vascular endothelial growth factor (VEGF) and clinicopathological factors were evaluated.

RESULTS

Although IL-12-positive cell density was not associated with serum levels of IL-12, the IL-12-positive cell density tended to increase in patients with serum levels of IL-12 higher than the mean level (p=0.0518). IL-12-positive cell density significantly decreased in the patients with CEA positive or differentiated type. Moreover, IL-12-positive cell density tended to be inversely correlated with plasma levels of VEGF (p=0.0801, r=-0.343).

CONCLUSION

These results suggest that the immune efficiency in patients with gastric cancer may be reflected by IL-12-positive cell density and serum levels of IL-12. Thus, patients with low IL-12-positive cell density or serum levels of IL-12 in gastric cancer may require additional immunochemotherapy after surgery.

[A case of advanced gastric cancer effectively treated by combined chemotherapy of paclitaxel (TXL) and CDDP]

The patient was a 73-year-old man with unresectable advanced gastric cancer and celiac and supraclavicular lymph node metastases. Neoadjuvant chemotherapy consisting of paclitaxel (TXL) and CDDP was administered. TXL (80 mg/m2) and CDDP (25 mg/m2) was administered weekly on day 1, 8 and 15 as 1 cycle. After 4 cycles of TXL/CDDP administration, the lymph node metastases and gastric tumor had decreased almost completely in size and distal partial gastrectomy was performed. After surgery, the patient was treated with 4 courses of TXL/CDDP and has survived without recurrence to the present. TXL/CDDP is associated with few adverse events in hospital visits, and is thought to be an effective chemotherapy against advanced gastric cancer.

Loss of inositol 1,4,5-trisphosphate receptors from bile duct epithelia is a common event in cholestasis

BACKGROUND AND AIMS

Cholestasis is one of the principal manifestations of liver disease and often results from disorders involving bile duct epithelia rather than hepatocytes. A range of disorders affects biliary epithelia, and no unifying pathophysiologic event in these cells has been identified as the cause of cholestasis. Here we examined the role of the inositol 1,4,5-trisphosphate receptor (InsP3R)/Ca(2+) release channel in Ca(2+) signaling and ductular secretion in animal models of cholestasis and in patients with cholestatic disorders.

METHODS

The expression and distribution of the InsP3R and related proteins were examined in rat cholangiocytes before and after bile duct ligation or treatment with endotoxin. Ca(2+) signaling was examined in isolated bile ducts from these animals, whereas ductular bicarbonate secretion was examined in isolated perfused livers. Confocal immunofluorescence was used to examine cholangiocyte InsP3R expression in human liver biopsy specimens.

RESULTS

Expression of the InsP3R was selectively lost from biliary epithelia after bile duct ligation or endotoxin treatment. As a result, Ca(2+) signaling and Ca(2+)-mediated bicarbonate secretion were lost as well, although other components of the Ca(2+) signaling pathway and adenosine 3',5'-cyclic monophosphate (cAMP)-mediated bicarbonate secretion both were preserved. Examination of human liver biopsy specimens showed that InsP3Rs also were lost from bile duct epithelia in a range of human cholestatic disorders, although InsP3R expression was intact in noncholestatic liver disease.

CONCLUSIONS

InsP3-mediated Ca(2+) signaling in bile duct epithelia appears to be important for normal bile secretion in the liver, and loss of InsP3Rs may be a final common pathway for cholestasis.

Prognostic significance of UDP-N-acetyl-alpha-D-galactosamine:polypeptide N-acetylgalactosaminyltransferase-3 (GalNAc-T3) expression in patients with gastric carcinoma

Aberrant glycosylation occurs during development of gastric carcinomas. The initiation of mucin-type O-glycosylation is regulated by GalNAc-T3 (UDP-N-acetylgalactosamine:polypeptide N-acetylgalactosaminyltransferase-3). However, the clinical significance of GalNAc-T3 expression in human gastric carcinoma has not yet been demonstrated. In the present study, we investigated the relationship between immunohistochemical GalNAc-T3 expression and various clinicopathologic factors, including prognosis, in 117 gastric carcinoma patients. Of 117 gastric carcinomas examined, 59 (50.4%) showed strong expression of GalNAc-T3. Strong expression was detected in 38 of 59 (64.4%) differentiated type and in 21 of 58 (36.2%) undifferentiated gastric carcinomas, indicating that the expression of GalNAc-T3 correlated significantly with tumor differentiation (P=0.0023, chi2 test). Overall 5-year survival rate in patients with strong GalNAc-T3 expression (71.0%) was significantly better than that of patients with weak expression (49.3%) (P=0.0197, log-rank test). Multivariate analysis identified GalNAc-T3 expression as an independent prognostic factor (P=0.0158, Cox proportional hazards model). Our data suggest that GalNAc-T3 expression may be a useful marker for prognosis and differentiation of gastric carcinomas.