A new endoscopic tattooing technique for identifying the location of colonic lesions during laparoscopic surgery: a comparison with the conventional technique

BACKGROUND AND STUDY AIMS

Knowledge of the exact location of colorectal lesions is necessary but difficult to establish during surgery. Thus, endoscopic tattooing has been used as an important preoperative marker for identification. Using the conventional technique, we injected tattooing agents directly into the colonic wall. However, to make sure that the tattooing agents were adequately injected into the submucosal layer, and to prevent spillage into the peritoneal cavity, we modified the conventional method and developed a new tattooing technique: using India ink with prior and subsequent injection of saline into the submucosa. The aim of this study was to retrospectively assess the clinical utility and potential complications of the above two techniques of endoscopic tattooing using India ink.

PATIENTS AND METHODS

A total of 153 patients underwent laparoscopically assisted colectomy at the National Cancer Center Hospital East, Kashiwa, Chiba, Japan, between June 1994 and December 1999, and 91 patients underwent preoperative endoscopic tattooing by either the conventional or the new technique. The conventional and new techniques were used from June 1994 to December 1997 (n = 36) and from January 1998 to December 1999 (n = 55), respectively. Informed consent was obtained from all the patients.

RESULTS

Using the conventional technique, the exact location of the lesion was identified in 31 of 36 cases (86.1 %) during surgery. The complications of this procedure were silent local peritonitis in two patients and reactive lymph node swelling in one patient (3/36, 8.3 %). Using the new technique, in 54 of 55 cases lesions (98 %) were easily identified (p = 0.034),and in only one there was a small leakage of India ink into the peritoneal cavity (1/55; 1.8 %), no other serious complications were observed.

CONCLUSIONS

The results demonstrate that our new technique for endoscopic tattooing is probably better than the conventional technique for clinical use, in terms of diagnostic accuracy and safety, but this would have to be proven in a randomized comparison.

Serum levels of apoptosis inhibitor of macrophage are associated with hepatic fibrosis in patients with chronic hepatitis C

Background

Apoptosis inhibitor of macrophage (AIM) and adipocytokines are involved in the metabolic syndrome, which has been putatively associated with the progression of chronic hepatitis C (CHC). However, the association between these cytokines and CHC is not fully elucidated. The aim of this study is to test whether serum levels of AIM and adipocytokines are associated with histological features, homeostasis model assessment-insulin resistance index (HOMA-IR), or whole body insulin sensitivity index (WBISI) in CHC patients.

Methods

Serum samples were obtained from 77 patients with biopsy-proven CHC. In 39 patients without overt diabetes mellitus, a 75 g oral glucose tolerance test (OGTT) was performed and HOMA-IR and WBISI were calculated.

Results

A serum AIM level of ≥1.2 μg/ml was independently associated with advanced hepatic fibrosis (F2 or F3) (odds ratio [OR], 5.612; 95% confidence interval [CI], 1.103–28.563; P = 0.038) based on a multivariate analysis, but there was no significant association between AIM and hepatic steatosis or inflammation. Furthermore, a serum leptin level of ≥8.6 ng/ml was independently associated with the presence of hepatic steatosis (≥5%) (OR, 6.195; 95% CI, 1.409–27.240; P = 0.016), but not hepatic fibrosis or inflammation. No relationship was observed between levels of adiponectin or resistin and hepatic histological parameters based on a multivariate analysis. Although serum levels of leptin, resistin, and adiponectin were significantly correlated with HOMA-IR and WBISI, there was no significant relationship between serum AIM levels and HOMA-IR or WBISI, respectively.

Conclusion

High serum levels of AIM in CHC patients are potentially related to advanced hepatic fibrosis. AIM and adipocytokines are possibly associated with pathological changes via a different mechanism.

Continuous microinstillation of phenol red on liver surface for liver site-selective delivery

We report a very promising approach for liver site-selective drug delivery through drug instillation on liver surface. Phenol red, which was selected as a model drug, was accumulated in the instillation site after instillation on the rat liver surface. The site-selective localization was enhanced by gradually and continuously instilling a small amount of drug solution on the liver surface.

Visualization of blood flow in hepatic vessels and hepatocellular carcinoma using B-flow sonography

PURPOSE

A B-flow sonographic technique was recently developed to provide direct visualization of blood flow with gray-scale sonography. Compared with color Doppler sonography, B-flow imaging has wideband resolution and a high frame rate. The purpose of this study was to evaluate the usefulness of B-flow sonography for visualizing blood flow in hepatic vessels and tumor vascularity in patients with liver cirrhosis or hepatocellular carcinoma (HCC).

METHODS

Twenty-five patients with liver cirrhosis, including 15 with HCC, were studied by B-flow and color Doppler sonography. Blood-flow detection rates in portal veins and hepatic arteries and tumor vascularity in HCC were analyzed, and the 2 methods were compared.

RESULTS

Using B-flow, blood flow was visualized in the portal vein in 23 (92%) of 25 patients and was visualized in the hepatic artery separately from the portal vein in 9 (36%) of 25 patients. The blood-flow signals were visualized only within vessels, never "bleeding" outside the vessel's lumen. Blood flow in the portal vein was observed with color Doppler sonography in all 25 patients, but the hepatic artery was never clearly separated from the portal vein. Vascularity within the HCC tumor was detected in 9 (60%) of 15 nodules with B-flow imaging, and fine arteries flowing into the tumor were observed in 6 nodules. Color Doppler sonography detected blood flow in 13 (87%) of the 15 HCC nodules.

CONCLUSIONS

Blood flow in hepatic vessels and tumor vessels of HCC were visualized with B-flow sonography. B-flow sonography is a potentially useful technique for the evaluation of liver vascularity and intratumoral vessels.

Sequential methotrexate and 5-fluorouracil therapy for gastric cancer patients with peritoneal dissemination: a retrospective study

BACKGROUND

Most gastric cancer patients with peritoneal dissemination have been excluded from clinical studies because they usually have no measurable lesions. They also have a high risk of toxicity because of complications such as intestinal obstruction and ascites. We conducted a retrospective analysis to evaluate the efficacy and feasibility of sequential methotrexate (MTX) and 5-flurorouracil (5FU) therapy for this population.

METHODS

This analysis was based on 56 consecutive chemotherapy-naive patients with confirmed peritoneal dissemination of gastric cancer who were being treated with sequential MTX/5FU. The therapy comprised a weekly schedule of MTX 100 mg/m2, given as a bolus infusion 3 h prior to a bolus infusion of 5FU 600 mg/m2. Leucovorin 10mg/m2 was administered six times, every 6h, starting 24h after MTX administration.

RESULTS

Evidence of peritoneal dissemination was confirmed by laparotomy in 16 patients, by cytologic examination of ascites in 11 patients, and by clinical imaging in 29 patients (15 with ascites, 13 with intestinal obstruction; in 10 of the 29 patients, detection was by barium enema or computed tomography [CT] scan). Neutropenia of grade 3 or worse and anemia were observed in 8 (14%) and 10 (18%) of the 56 patients, respectively. There was one treatment-related death due to neutropenic sepsis. Of the 26 patients with measurable lesions, 9 showed a response (36%). The median survival time and median time to treatment failure were 259 days and 167 days, respectively. Objective improvement of ascites was seen in 13 of 26 patients (50%), including 5 with showed complete disappearance of ascites. Seven of the 15 patients (47%) with intestinal obstruction showed resolution, and 8 of the 21 patients (38%) who needed nutritional support before the treatment were free of that support for a median duration of 220 days after the completion of the treatment. Forty-seven of the 56 patients (84%) could be treated at outpatient clinics.

CONCLUSIONS

This regimen may be of clinical benefit for patients with peritoneal dissemination of gastric cancer.

Assessment of arterial tumor vascularity in small hepatocellular carcinoma. Comparison between color doppler ultrasonography and radiographic imagings with contrast medium: dynamic CT, angiography, and CT hepatic arteriography

Hepatocellular carcinoma (HCC) is characterized by tumor vascularization from the hepatic artery. The objective of our work was to compare color Doppler ultrasonography (CDU), including power Doppler ultrasonography (PDU) with radiographic imagings with contrast medium in regard to the detection of the arterial tumor vascularity of small hepatocellular carcinomas (HCC). We examined 42 small HCC lesions 2 cm or less in diameter in 37 patients for arterial tumor vascularity by conventional CDU, PDU, dynamic computed tomography (dCT), digital subtraction angiography (DSA), and CT hepatic arteriography (CTA). Color images were detected in 25 (59.5%) and 28 (66.7%) of the 42 lesions with conventional CDU and PDU, respectively, and tumor vascularity was detected in 26 (61.9%) by dCT, 23 (54.8%) by DSA, and 29 (69.0%) by CTA. Tumor vascularity could be detected in 51.9% by PDU and CTA, more than by conventional CDU, dCT, and DSA (44.4, 44.4, and 33.3%, respectively) in well-differentiated HCC, whereas the detection rates by these techniques were almost equal (86.7% by CDU, 93.3% by PDU, dCT, and DSA, 100% by CTA, respectively) in moderately and poorly differentiated HCC. PDU is superior to CDU, dCT and DSA and equal to CTA for the detection of tumor vascularity in small HCC, particularly in well-differentiated HCC.

Clinical significance of magnetic resonance cholangiopancreatography for the diagnosis of cystic tumor of the pancreas compared with endoscopic retrograde cholangiopancreatography and computed tomography

BACKGROUND

Cystic tumor of the pancreas has been investigated by a variety of imaging techniques. Magnetic resonance cholangiopancreatography (MRCP) is being widely used as a non-invasive diagnostic modality for investigation of the biliary tree and pancreatic duct system. The purpose of this study was to compare MRCP images with those of endoscopic retrograde cholangiopancreatography (ERCP) and computed tomography (CT) in order to clarify the diagnostic efficacy of MRCP for cystic tumor of the pancreas.

METHODS

We retrospectively studied 15 patients with cystic tumor of the pancreas that had been surgically resected and histopathologically confirmed. There were five cases of intraductal papillary adenocarcinoma, five of intraductal papillary adenoma, two of serous cyst adenoma, two of retention cyst associated with invasive ductal adenocarcinoma and one of solid cystic tumor.

RESULTS

In all cases MRCP correctly identified the main pancreatic duct (MPD) and showed the entire cystic tumor and the communication between the tumor and the MPD. On the other hand, the detection rate by ERCP of the cystic tumor and the communication between the cystic tumor and the MPD was only 60%. Although the detection rates by CT for the septum and solid components inside the cystic tumor were 100 and 90.0%, respectively, those of MRCP for each were 58.3 and 20.0%.

CONCLUSION

MRCP is capable of providing diagnostic information superior to ERCP for the diagnosis of cystic tumor of the pancreas. Although MRCP may provide complementary information about the whole lesion of interest, the characteristic internal features of cystic tumor of the pancrease should be carefully diagnosed in combination with CT.

Hepatic expression of the Sptlc3 subunit of serine palmitoyltransferase is associated with the development of hepatocellular carcinoma in a mouse model of nonalcoholic steatohepatitis

The molecular mechanisms underlying the progression of nonalcoholic steatohepatitis (NASH) have not been fully elucidated. The aim of this study was to identify factors involved in NASH progression by analysis of pathophysiological features and gene-expression profiles in livers of STAM mice, a model of NASH-associated hepatocarcinogenesis. C57BL/6N (B6N) mice were injected with streptozotocin to generate STAM mice. Four-week-old male STAM and B6N mice were fed a high-fat diet (HFD) (STAM-F, B6N-F) or a conventional diet (STAM-C, B6N-C) until they were 10, 14, or 18 weeks old. Blood glucose and nonalcoholic fatty liver disease (NAFLD) activity scores of STAM-F were higher than those of STAM-C during all observation periods. STAM-F mice had more severe hepatic fibrosis at 14 weeks, and exhibited higher levels of α-fetoprotein-positive hepatic tumor formation with multiplication than STAM-C mice at 18 weeks. At 14 weeks, cDNA microarray analysis revealed that the hepatic expression of eight mRNAs was ≥30-fold higher in STAM-F than B6N-F mice. The expression of another four genes was increased ≥5-fold in STAM-F than B6N-F mice, and ≥5-fold in B6N-F relative to B6N-C mice. Of the 12 genes, the difference in Sptlc3 mRNA expression was most pronounced, and gradually increased over time, as determined by quantitative RT-PCR in STAM-F mice. In addition, Sptlc3 mRNA expression in STAM-F mice was higher than that in db/db mice that received HFD and in B6N mice fed a choline‑deficient L-amino acid (CDAA)-defined diet. In conclusion, a high-fat diet aggravated pathophysiological findings in the liver in NASH mouse models, and the hepatic expression of Sptlc3 mRNA was potentially associated with NASH progression.

Incidental detection of breast cancer during T1-201 myocardial SPECT study

A case of left breast cancer which was detected incidentally by T1-201 SPECT performed to evaluate the status of myocardial perfusion, is reported. Both stress and redistribution T1-201 SPECT clearly delineated the tumor. It was confirmed later as scirrhous carcinoma of the breast.

Midazolam for continuous sedation in Japanese critical care patients: phase II study

This prospective study was undertaken to evaluate the efficacy and safety of midazolam as a sedative agent in 14 critically ill patients without coma admitted to the intensive care unit at Nihon University Itabashi Hospital, Japan. Adequate sedation (sedation score [SS] 4-6) was induced with 0.058- 0.372 mg/ kg midazolam and maintained with a dose range of 0.03-0.4 mg/kg per h. Most burn or trauma patients required higher midazolam doses than patients with cardiovascular disease. The most frequent adverse events observed were hypotension, heart-rate fluctuation and electrocardiogram abnormalities. Pharmacokinetic analysis of the population suggested that lower drug clearance rates correlated with presence of complications. Plasma concentrations (EC50) of SS 5, estimated by logistic regression analysis, varied among patients (mean 194 ng/ml). Midazolam infusion achieved successful sedation in this critical care setting, but the optimum dose differed by patient and was influenced by the presence of complications.

High serum thioredoxin levels are reduced after tonsillectomy in patients with IgA nephropathy

OBJECTIVE

The role of oxidative stress in IgA nephropathy (IgAN), the most common type of primary glomerulonephritis, is unknown. We evaluated the clinical significance of serum levels of oxidative stress markers, thioredoxin (TRX) and manganese superoxide dismutase (MnSOD), in patients with IgAN.

METHODS

Forty-eight patients with histologically confirmed IgAN and 14 healthy subjects were enrolled in this study. Serum samples from 14 IgAN patients were obtained after tonsillectomy, a procedure hypothesized to be an effective treatment for IgAN.

RESULTS

Serum TRX levels were significantly higher in patients with IgAN than in healthy subjects (mean [ng/mL]; 49.5 vs.14.4, p<0.001). Serum TRX levels are positively correlated with blood urea nitrogen, serum uric acid and proteinuria, and negatively with estimated glomerular filtration rate (eGFR). In addition, serum TRX levels gradually increased as the severity of renal histology increased. High levels of serum TRX were significantly decreased after tonsillectomy in patients with IgAN (mean [ng/mL]; 55.5 to 41.1, p=0.02). In contrast, serum MnSOD levels did not differ between IgAN patients and healthy subjects, and these levels did not change after tonsillectomy in IgAN patients.

CONCLUSION

Serum TRX is associated with IgAN, and tonsillectomy may decrease oxidative stress in IgAN patients, leading to clinical improvement.

Population stabilization and national spatial policy of public investment: the Japanese experience

"This paper presents a new method that can be used to reveal the policy objectives with which actual public investment decisions are consistent. Japanese regional investment expenditures from 1958 to 1978 are analyzed, and the dominant policies in effect during this period are identified using this method. A connection between Japanese regional public investment policies and the convergence of population growth across regions is suggested." The suitability of redistributive investment policies as a mechanism for the spatial stabilization of other populations experiencing rapid economic growth is noted.

Combination of endoscopic mucosal resection and chemoradiotherapy as a nonsurgical treatments for patients with clinical stage I esophageal squamous cell carcinoma

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Background: Endoscopic mucosal resection (EMR) has become the standard treatment for mucosal cancer. For the other clinical stage I esophageal squamous cell carcinoma (ESCC), radical surgery is standard and chemoradiotherapy (CRT) is optional but has high locoreginoal failure. If EMR and CRT are combined efficiently, these may improve outcomes with less invasion. A retrospective analysis was conducted to evaluate the efficacy of these combined nonsurgical modalities. Methods: Recruitment criteria were histologically proven SCC, clinically estimated as stage I except for the candidates of the standard EMR, age ≤ 75, PS ≤ 2, no prior therapy, no serious complication and no other active malignancy. Primary EMR was indicated if a tumor was within the focal submucosal (SM) invasion and a width of less than two-thirds of its circumference. EMR was followed by prophylactic CRT (5-FU + cisplatin + RT; 40Gy) for latent node metastasis when SM invasion was present pathologically. The remaining patients (pts) underwent primary CRT (5-FU + cisplatin + RT; 60Gy); salvage EMR was indicated for local residual, recurrent, or metachronous tumors. Results: Between Jan. 1996 and Apr. 2004, 86 pts fulfilled the criteria; median age 60 years (46–75), male/female; 74/12. Forty-one received primary EMR and 45 received primary CRT. Pathological diagnoses of primary EMR revealed eight mucosal cancers of the epithelium and lamina propria, 19 of the musclaris mucosae (MM), and 14 SM cancers. Eleven pts with SM cancers subsequently underwent prophylactic CRT, one with SM cancer underwent surgery, and the remaining 29 pts with mucosal and MM cancers received no additional treatment. Of the 45 CRT pts, 11 (24%) received salvage EMR. Three (3%) (one primary EMR pt and two primary CRT pts) underwent salvage surgery. With a median follow-up of 4.2 years, the 4-year overall survival of all, primary EMR, and primary CRT pts was 76%, 78%, and 72%, respectively; the disease-specific survival was 86%, 91%, and 81%, respectively. Conclusion: The survival of combination treatment with EMR and CRT for clinical stage I ESCC was comparable with that of surgery in Japan. EMR and/or CRT may be highly effective, minimally invasive treatments for stage I ESCC.

No significant financial relationships to disclose.

The emergence of migration cycles?

"With a more thorough examination of population changes in the Tokyo region, this article confirms with regard to Japan the reconcentrating trend of urban population observed more clearly elsewhere by Cochrane and Vining (1988). Through an examination of the factors which led to the turnaround in the 1980s in Japan and elsewhere, it is argued that conservative economic policy, as manifested by deregulation and privatization, is the principal cause for reconcentration of urbanization in the 1980s in the economically advanced Western countries."

Efficacy of systemic chemotherapy (CT) for the patients (pts) with unresectable liver metastasis (LM) of colorectal cancer (CRC)

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Background: Surgical resection of colorectal LM is the only treatment which provides long-term survival for pts with advanced disease confined to the liver. However, most of LM are initially unresectable. The aim of this retrospective study was to evaluate the efficacy of systemic CT for the pts with initially unresectable LM from CRC. Methods: Subjects of this study were advanced CRC with unresectable LM treated by systemic CT at our institution between Aug ’92 and Dec ’03, and fulfilled the following criteria; Age ≤ 75, PS ≤ 2, histologically confirmed colorectal adenocarcinoma, no extrahepatic disease, no prior CT and no serious complication. Results: A total of 349 pts with metastatic CRC were managed by systemic CT between the period. Among these, there were 47 pts who met the recruitment criteria. Their characteristics were; male/female: 32/15, median age (range): 59 (34–75), PS 0/1/2: 33/12/2, primary tumor: colon/rectum: 26/21, sinchronous/metachronous: 26/21, number of LM: 4 ≥ / 5 ≤: 9/38. Regimens of CT were; 5FU/5FU+LV/CPT-11+5FU/CPT-11+5FU+LV/Others: 4/11/7/18/7. In all 47 pts, response rate was 53%, median survival time and 3-year survival rate were 14.6 month and 14.6%, respectively, at a median follow-up of 43.4 month. Seven of 47 (15%) could be secondarily resected after response to CT and all had R0 resection. Estimated 3-year survival rates in resected and non-resected pts were 57.1% and 0%, respectively. Prior CT before liver resection was CPT-11+5FU+LV (IFL)/CPT-11 alone: 6/1. Of the 7 resected pts, 2 pts are alive with no evidence of disease for 38 and 40 month after initiation of CT. Five of 7 pts relapsed (liver 3, liver and lung 2) and all treated with systemic CT for recurrence. Although recurrent disease is persisting, 2 of 5 are still alive for 34 and 48 month by continuing CT. Conclusions: Effective systemic CT allows some pts with unrsectable colorectal LM to be rescued by hepatic resection and provides a chance of long-term survival.

No significant financial relationships to disclose.