Results of a national survey on laparoscopic bariatric surgery in Japan, 2000-2009.

INTRODUCTION: In Japan, laparoscopic bariatric surgery has not been popular until recently because morbidly obese patients were infrequently encountered previous and Japanese health insurance does not cover this type of surgery. In 2010, the Japan Research Society for Endoscopic and Laparoscopic Treatments of Obesity undertook the first nationwide survey on laparoscopic bariatric surgery to evaluate its current status and outcomes. METHODS: A mail survey was sent to the society's 64 member institutions, which included almost all institutions in Japan actively performing laparoscopic gastrointestinal surgery. RESULTS: From 2000 to 2009, 340 laparoscopic bariatric procedures, in total, were performed in nine of the 64 institutions (14%). The most popular procedure was laparoscopic Roux-en-Y gastric bypass (LRYGB, n=147), second was laparoscopic sleeve gastrectomy (LSG, n=102), and third was laparoscopic adjustable gastric banding (LAGB, n=55). However, the number of LRYGB procedures has decreased while the number of LSG procedures has rapidly increased. Total morbidity rates were 12.2% for LRYGB, 10.9% for LAGB, and 7.8% for LSG. Percent excess weight loss was 78% at 5 years after LRYGB, 52% at 4 years after LAGB, and 68% at 2 years after LSG. Although the bariatric procedures frequently resolved or improved obesity-related comorbidities, LRYGB appears to be superior to LAGB, as was previously reported. CONCLUSION: The first nationwide survey of laparoscopic bariatric surgery in Japan clearly showed the current status and outcomes of this group of procedures. The Japanese results appear to be comparable to similarly undertaken surveys in Europe and the USA.

Endoscopic retreatment of recurrent choledocholithiasis after sphincterotomy.

BACKGROUND: Endoscopic sphincterotomy (ES) carries a substantial risk of recurrent choledocholithiasis but retreatment with endoscopic retrograde cholangiopancreatography (ERCP) is safe and feasible. However, long term results of repeat ERCP and risk factors for late complications are largely unknown. AIMS: To investigate the long term outcome of repeat ERCP for recurrent bile duct stones after ES and to identify risk factors predicting late choledochal complications. METHODS: Eighty four patients underwent repeat ERCP, combined with ES in 69, for post-ES recurrent choledocholithiasis. Long term outcomes of repeat ERCP were retrospectively investigated and factors predicting late complications were assessed by multivariate analysis. RESULTS: Complete stone clearance was achieved in all patients. Forty nine patients had no visible evidence of prior sphincterotomy. Two patients experienced early complications. During a follow up period of 2.2-26.0 years (median 10.9 years), 31 patients (37%) developed late complications, including stone recurrence (n = 26), acute acalculous cholangitis(n = 4), and acute cholecystitis (n = 1). There were neither biliary malignancies nor deaths attributable to biliary disease. Multivariate analysis identified three independent risk factors for choledochal complications: interval between initial ES and repeat ERCP < or =5 years, bile duct diameter > or =15 mm, and periampullary diverticulum. Choledochal complications were successfully treated with repeat ERCP in 29 patients. CONCLUSIONS: Choledochal complications after repeat ERCP are relatively frequent but are endoscopically manageable. Careful follow up is necessary, particularly for patients with a dilated bile duct, periampullary diverticulum, or early recurrence. Repeat ERCP is a reasonable treatment even for recurrent choledocholithiasis after ES.

An increased high-mobility group A2 expression level is associated with malignant phenotype in pancreatic exocrine tissue.

The altered form of the high-mobility group A2 (HMGA2) gene is somehow related to the generation of human benign and malignant tumours of mesenchymal origin. However, only a few data on the expression of HMGA2 in malignant tumour originating from epithelial tissue are available. In this study, we examined the HMGA2 expression level in pancreatic carcinoma, and investigated whether alterations in the HMGA2 expression level are associated with a malignant phenotype in pancreatic tissue. High-mobility group A2 mRNA and protein expression was determined in eight surgically resected specimens of non-neoplastic tissue (six specimens of normal pancreatic tissue and two of chronic pancreatitis tissue) and 27 pancreatic carcinomas by highly sensitive reverse transcriptase-polymerase chain reaction (RT-PCR) techniques and immunohistochemical staining, respectively. Reverse transcriptase-polymerase chain reaction analysis revealed the expression of the HMGA2 gene in non-neoplastic pancreatic tissue, although its expression level was significantly lower than that in carcinoma. Immunohistochemical analysis indicated that the presence of the HMGA2 gene in non-neoplastic pancreatic tissue observed in RT-PCR reflects its abundant expression in islet cells, together with its focal expression in duct epithelial cells. Intense and multifocal or diffuse HMGA2 immunoreactivity was noted in all the pancreatic carcinoma examined. A strong correlation between HMGA2 overexpression and the diagnosis of carcinoma was statistically verified. Based on these findings, we propose that an increased expression level of the HMGA2 protein is closely associated with the malignant phenotype in the pancreatic exocrine system, and accordingly, HMGA2 could serve as a potential diagnostic molecular marker for distinguishing pancreatic malignant cells from non-neoplastic pancreatic exocrine cells.

Predictive factors for malignancy in intraductal papillary-mucinous tumours of the pancreas.

BACKGROUND: Preoperative assessment of the likelihood of malignancy in intraductal papillary-mucinous tumour (IPMT) of the pancreas is often difficult. Predictive factors for malignancy and invasive carcinoma in IPMT were analysed. METHODS: Sixty-two patients with IPMT underwent surgical treatment, with histological confirmation of adenoma in 28, carcinoma in situ in 14 and invasive carcinoma in 20. Tumours were of the main duct type in 14 patients, branch duct type in 32, and combined type in 16. A multivariate analysis of 17 potential predictive factors, including preoperative clinical and imaging findings, was conducted. RESULTS: Multivariate analysis identified two independent predictive factors for malignancy: mural nodules and main pancreatic duct diameter of 7 mm or more. Mural nodules in the main duct or combined type, and mural nodules and tumour diameter of 30 mm or more in the branch duct type were particularly indicative of malignancy. Mural nodules, jaundice and main duct or combined type were predictors of invasive carcinoma in the multivariate analysis. CONCLUSION: The above factors should be considered in the diagnosis of IPMT to facilitate appropriate management.

Anomalous pancreaticobiliary junction demonstrated by extraductal ultrasonography using transduodenoscopic miniprobe.

We present a case of an anomalous pancreaticobiliary junction (a long common channel) that was clearly demonstrated by extraductal ultrasonography with a transduodenoscopic miniprobe placed in the duodenal lumen. The present case suggests a potential indication for the ultrasound miniprobe, in extraductal ultrasonography, in the pancreatobiliary region. In this method, the position of a miniprobe can readily be adjusted under endoscopic guidance, unlike ordinary endoscopic ultrasonography.

Possible contribution of CD44 variant 6 and nuclear beta-catenin expression to the formation of budding tumor cells in patients with T1 colorectal carcinoma.

BACKGROUND: In an earlier study, the authors demonstrated that tumor budding was useful for predicting lymph node metastasis in patients with early invasive (T1) colorectal carcinoma. This study was undertaken to clarify the associations between tumor budding, E-cadherin-catenin complex, and CD44 variant 6 abnormalities. METHODS: In 51 T1 colorectal carcinomas, tumor budding (the number of dedifferentiation units at the invasive margin) on hematoxylin and eosin-stained slides was counted under light microscopy. Immunostaining for E-cadherin, alpha-catenin, beta-catenin, and CD44 variant 6 was performed on formalin fixed, paraffin embedded sections. The associations between locoregional failure (lymph node metastasis or local recurrence) and tumor budding and clinicopathologic parameters and immunoreactivity were examined statistically. RESULTS: In univariate analysis, tumor budding and nuclear beta-catenin expression were associated significantly with locoregional failure (P = 0.004, 0.01). Multivariate analysis showed that tumor budding alone was associated significantly with locoregional failure (P = 0.02), and the association between nuclear beta-catenin expression and locoregional failure was marginally significant (P = 0.07). Analysis of variance showed that lymphatic invasion alone was associated significantly with tumor budding (P = 0.02), and there was a significant interaction effect for tumor budding between CD44 variant 6 expression and nuclear beta-catenin expression (P = 0.01). There was a significant correlation between expression patterns of these two molecules and locoregional failure (P = 0.01). CONCLUSIONS: The current results suggest that the up-regulation of CD44 variant 6 through nuclear beta-catenin activation may contribute to the formation of tumor budding, and immunostaining of these two adhesion molecules may be useful in identifying those at high-risk for locoregional failure among patients with T1 colorectal carcinoma.

Groin hernias in adults: value of color Doppler sonography in their classification.

PURPOSE: We assessed the abilities of color Doppler and power Doppler sonography to distinguish among types of groin hernias by demonstrating the inferior epigastric artery (IEA) and its relationship with the hernia sac. METHODS: Nineteen consecutive patients (14 men and 5 women), clinically diagnosed as having groin hernias and scheduled to undergo herniorrhaphy, were prospectively enrolled in this study. Ultrasound examinations were performed preoperatively with a 6-12-MHz linear-array transducer. The IEA was identified, if possible, and its relationship to the hernia sac assessed. The sonographic diagnoses were compared with the operative findings. RESULTS: There were 15 indirect inguinal hernias, 4 direct inguinal hernias, and 1 femoral hernia; 1 patient had bilateral inguinal hernias (indirect and direct). In 18 (90%) of 20 hernia cases, the trunk segment of the IEA could be visualized. In 11 (55%) of 20 hernia cases, the origin segment of the IEA could be visualized and its relationship with the hernia sac assessed. In 9 (82%) of the 11 hernia cases, hernia types were correctly diagnosed by sonography. The overall accuracy of sonography for diagnosing the type of hernia was 45% (9 of 20 hernias). CONCLUSIONS: Color Doppler sonography can accurately differentiate types of groin hernias if the origin segment of the IEA and the hernia sac can be visualized simultaneously. However, color Doppler sonography sometimes failed to visualize this segment.

Colonoscopic treatment of colon cancers.

Recent advances in endoscopic technology have enabled conservative treatment for patients with carcinoma in situ. The treatment of submucosally invasive carcinomas, or malignant polyps, is still controversial, however. The use of widely advocated histologic criteria, such as poorly differentiated histology (Grade III cancer), level 4 invasion or involved margin status, or lymphatic venous invasion as risk factors for adverse outcome, should be examined by multivariate analysis. Unfavorable histology at the invasive margin, PCNA, MUC-1 expression, and chromosomal abnormalities may be new candidates for prognostic indicators in patients with submucosally invasive carcinoma.

Pancreatic transection using ultrasonic dissector in pancreatoduodenectomy.

BACKGROUND: Pancreatoenterostomic leakage after pancreatoduodenectomy may be caused partly by pancreatic juice leakage from transected branch pancreatic ducts on the pancreatic cut surface that do not drain into the main pancreatic duct after pancreatectomy. METHODS: We devised a new technique of pancreatic transection using an ultrasonic dissector followed by duct-to-mucosa pancreatojejunostomy, in order to prevent pancreatoenterostomic leakage after pancreatoduodenectomy in patients with a soft pancreas and a small main pancreatic duct. During pancreatic transection, branch pancreatic ducts and blood vessels are adequately skeletonized and securely ligated. The pancreatic duct is anastomosed to the full thickness of the jejunum with four to six interrupted sutures. RESULTS: Ten patients with a nondilated pancreatic duct (2 to 3 mm) underwent pancreatoduodenectomy by the present method. During pancreatic transection, 24 to 35 ducts including the pancreatic ducts and blood vessels were skeletonized and ligated. Postoperatively, no patients developed pancreatojejunostomic leakage. The present method may prevent pancreatoenterostomic leakage after pancreatoduodenectomy.

Medium-term effects of endoscopic papillary balloon dilation on gallbladder motility.

BACKGROUND: Endoscopic papillary balloon dilation (EPBD) for removal of bile duct stones tends to preserve papillary function. However, EPBD may exert beneficial or deleterious effects on gallbladder motility. This was a prospective, medium-term investigation (2 years) of the effects of EPBD on gallbladder motility. METHODS: Twelve patients with intact gallbladders (6 with and 6 without gallbladder stones) who underwent EPBD for choledocholithiasis were enrolled in this study. Gallbladder motility was examined before EPBD and at 7 days, 1 month, 1 year, and 2 years after EPBD. Gallbladder volumes, measured after fasting and after ingestion of dried egg yolk, were determined by US. RESULTS: All patients were asymptomatic during the 2-year follow-up period. Before EPBD, particularly in patients with cholelithiasis, the gallbladder had a larger fasting volume and lower yolk-stimulated maximum contraction compared with normal control subjects. Seven days after EPBD, fasting volume was decreased and maximum contraction was increased, both significantly compared with pre-EPBD values and regardless of the presence or absence of gallbladder stones. At 1 month, 1 year, and 2 years after EPBD, these changes were far less evident and gallbladder function did not differ significantly from baseline. CONCLUSION: EPBD does not adversely affect gallbladder motility in the medium-term (2 years). In terms of gallbladder motility, EPBD does not appear to increase the future risk of acute cholecystitis or gallbladder stone formation.

Magnetic resonance cholangiopancreatography for diagnosing hepatolithiasis.

BACKGROUND/AIMS: Direct cholangiography with endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography sometimes fails to adequately opacify the entire biliary tract, because of severe biliary obstruction caused by ductal stricture or lodged stones. We assessed the diagnostic accuracy of magnetic resonance cholangiopancreatography for hepatolithiasis. METHODOLOGY: Five patients with hepatolithiasis underwent ultrasonography, computed tomography, direct cholangiography, and magnetic resonance cholangiopancreatography, using a half-Fourier acquisition single-shot turbo spin-echo sequence. Surgical exploration or pathologic examination revealed stricture and dilatation of the intrahepatic ducts in all patients. Diagnostic accuracies for stones and ductal abnormalities were compared among the imaging studies. RESULTS: No complications occurred during magnetic resonance cholangiopancreatography studies. Magnetic resonance cholangiopancreatography fully depicted the biliary tract. Magnetic resonance cholangiopancreatography accurately detected and localized intrahepatic stones, as well as bile duct stricture and dilatation, in all patients. Intrahepatic stones were detected by endoscopic retrograde cholangiopancreatography in one of four patients and by percutaneous transhepatic cholangiography in all three who underwent this procedure. Endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography demonstrated ductal stricture in all patients but failed to completely demonstrate the biliary tree in three of four patients, and one of three, respectively. On ultrasonography and computed tomography, precise localization of stones was difficult. Ultrasonography and computed tomography failed to demonstrate ductal stricture in one and two of the five patients, respectively. CONCLUSIONS: Magnetic resonance cholangiopancreatography diagnoses intrahepatic stones and bile duct abnormalities less invasively and more accurately than endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography.

Periampullary diverticula cause pancreatobiliary reflux.

BACKGROUND: Periampullary diverticula are associated with dysfunction of the sphincter of Oddi. Papillary dysfunction may allow reflux of pancreatic juice as well as intestinal contents into the common bile duct. We prospectively investigated pancreatobiliary reflux in patients with and without periampullary diverticula. METHODS: The ductal bile was sampled for amylase concentration during endoscopic retrograde cholangiopancreatography in 47 patients with choledocholithiasis (n = 29; with (n = 14) or without (n = 15) periampullary diverticula) or gallbladder cholesterol polyps (n = 18; with (n = 6) or without (n = 12) diverticula). RESULTS: The amylase concentration within the ductal bile was significantly higher in choledocholithiasis patients with periampullary diverticula (1621 +/- 587 IU/l) than in those without diverticula (1155 +/- 418 IU/l). The amylase concentration tended to be higher in gallbladder polyp patients with diverticula (1087 +/- 275 IU/l) than in those without diverticula (833 +/- 272 IU/l). Irrespective of the presence or absence of diverticula, patients with bile duct stones had significantly higher amylase concentrations than those with gallbladder polyps. CONCLUSIONS: Periampullary diverticula cause pancreatobiliary reflux. Further investigation is required to determine the clinical implication of pancreatobiliary reflux.

Prognostic significance of carcinoembryonic antigen levels in peritoneal washes in patients with gastric cancer.

BACKGROUND: Peritoneal metastasis is the most frequent cause of death in patients with gastric cancer. Detection of free cancer cells in the peritoneal cavity at the time of surgery, therefore, is considered to be of great value in predicting the peritoneal recurrence and accordingly in the prognosis in patients with gastric cancer. This study examined the clinical significance of intraoperative determination of carcinoembryonic antigen (CEA) levels in peritoneal washes (pCEA) in patients with gastric cancer. METHODS: CEA levels in peritoneal washes were correlated retrospectively with several clinicopathologic factors including clinical outcome in 56 patients with resectable gastric cancer. RESULTS: Among several clinicopathologic factors, the depth of tumor invasion significantly and independently correlated with pCEA levels as revealed by multivariate stepwise logistic regression analysis. A significant difference in overall survival rates was observed between pCEA-positive and pCEA-negative groups: 5-year survival rates were 95.7% in pCEA-negative and 20% in pCEA-positive patients (P <0.0001). Multivariate analysis indicated that pCEA level is a statistically significant independent prognostic factor for the survival of patients with gastric cancer, and is an important factor for predicting peritoneal recurrence. CONCLUSIONS: pCEA could be a potential predictor of a poor prognosis as well as peritoneal recurrence in patients with gastric cancer. We believe that this information could contribute to determining the optimal intraoperative and postoperative therapeutic plan including adjuvant chemotherapy of gastric cancer.

Continuous regional arterial infusion (CRAI) therapy reduces the mortality rate of acute necrotizing pancreatitis: results of a cooperative survey in Japan.

We evaluated the usefulness of continuous regional arterial infusion (CRAI) of protease inhibitors and antibiotics in 156 patients with acute necrotizing pancreatitis (ANP) collected in a cooperative survey carried out in 1997 in Japan. The overall mortality rate was 18.6%, and the frequency of infected pancreatic necrosis was 12.8%. There was no significant difference in mortality rates between patients who received the protease inhibitor via CRAI and the antibiotics intravenously (group A) and patients who received both the protease inhibitor and the antibiotics via CRAI (group B), but the frequency of infected pancreatic necrosis was significantly lower in group B (7.6%) than in group A (23.5%). The mortality rate in patients in whom CRAI therapy was initiated within 48 h after the onset of ANP (11.9%) was significantly lower than that in patients in whom CRAI therapy was initiated more than 48 h after the onset (23.6%). These results suggested that CRAI of both protease inhibitors and antibiotics was effective in reducing mortality and preventing the development of pancreatic infection in ANP when initiated within 48 h after the onset of ANP.

Opsonin receptor expression on peritoneal exudative and circulatory neutrophils in murine acute pancreatitis.

Acute severe (necrotizing) pancreatitis is often associated with pancreatic or peripancreatic infection. Decreased bacterial clearance due to impaired immune defense may cause local infection. We investigated expressions of surface opsonin receptors (CD11b, complement receptor 3; CD32/CD16, immunoglobulin G Fc receptor) on local and circulatory neutrophils, in murine acute pancreatitis. The mild and severe forms of acute pancreatitis were induced by seven and 13 subcutaneous injections of caerulein, respectively. Peritoneal exudative and circulatory neutrophils were counted and assayed for receptor expressions by flow cytometry, serially at 1-72 hours after pancreatitis induction. Histologically, mild and severe forms showed edematous and necrotizing pancreatitis, respectively. The peritoneal exudative neutrophil count was greater in mild than in severe pancreatitis. Expressions of CD11b and CD32/CD16 on local neutrophils were upregulated early in mild pancreatitis. This upregulation was attenuated in severe pancreatitis. The circulatory neutrophil count was elevated in severe pancreatitis but was unchanged in mild pancreatitis. Opsonin receptor expression on circulatory neutrophils showed a transient, modest upregulation in the early phase of mild pancreatitis. Receptor-positive circulatory neutrophils showed a marked elevation that persisted throughout the course of severe pancreatitis. In conclusion, severe (necrotizing) pancreatitis is associated with reduced opsonin receptor expression on local neutrophils and enhanced expression on circulatory neutrophils, as compared with mild (edematous) pancreatitis. These changes may contribute to local infectious complications and multiple organ failure, in severe pancreatitis.

Peroral jejunoscopy for treating stenosis of hepaticojejunostomy after pancreatoduodenectomy.

A 72-year-old woman suffered from relapsing cholangitis after pylorus-preserving pancreatoduodenectomy for chronic pancreatitis. The common hepatic duct had been anastomosed to the jejunum 8 cm distal to the duodenojejunostomy. Peroral jejunoscopy showed a severe stenosis of the hepaticojejunostomy, which was endoscopically enlarged by means of electroincision and balloon dilation, subsequently. No procedure-related complications occurred. The patient has been asymptomatic for 34 months. Most of the strictures of bilioenterostomy are reportedly treated by surgical revision, the percutaneous transhepatic approach, or the percutaneous transjejunal approach. Endoscopic treatment may be attempted in cases in which the postoperative anatomy potentially allows endoscopic access, because of its minimal invasiveness and effectiveness.

Quantitative analysis of telomerase activity: a potential diagnostic tool for colorectal carcinoma.

BACKGROUND/AIMS: We describe the results of the application of the nonradioactive F-TRAP (fluorescence-based telomeric repeat amplification protocol) assay for the diagnosis of colorectal carcinoma(s). We also investigated whether the level of telomerase activity in colorectal carcinoma can be distinguished from that in normal colorectal tissue or benign colorectal tumors, in which the presence of telomerase activity has also been demonstrated. In addition, we also investigated whether it could be a potential tumor progression marker. METHODOLOGY: The F-TRAP assay was performed, using biopsy specimens obtained from colonoscopic examinations, including 20 colorectal carcinoma, 10 tubular adenoma and 20 adjacent colorectal normal tissue specimens. In 15 carcinoma cases, the correlation between telomerase activity level and clinicopathological parameters was analyzed. RESULTS: The results showed that the level of telomerase activity in colorectal carcinomas (88.71 +/- 92.1 units; mean +/- SD) was much higher than that in normal colorectal tissues (3.34 +/- 8.57 units) or adenomas (7.8 +/- 10.27 units). By quantifying the level of telomerase activity using the F-TRAP assay, colorectal carcinomas can be distinguished from normal colorectal tissue or colorectal benign tumors. However, no significant correlation was observed between telomerase activity levels and clinicopathological parameters such as depth of tumor invasion, lymphatic and/or venous involvement, and regional lymph node metastasis and Dukes' stage. CONCLUSIONS: Quantitative analysis of the level of telomerase activity using the F-TRAP assay provides a useful diagnostic tool for colorectal carcinoma, but it would not be useful as a tumor progression marker.

The indication of local excision for T2 rectal carcinomas.

BACKGROUND: Several researchers reported that local excision with or without postoperative chemo-radiation therapy is an alternative approach for sphincter preservation in patients with locally invasive rectal carcinoma. However, indications and long-term results have not yet been determined. METHODS: Seventy-two patients with T2 colorectal carcinomas underwent bowel resection with regional lymph node dissection. The associations between lymph node metastasis (LNM) and clinicopathologic factors were examined with special reference to the presence or absence of moderate to severe degree of focal dedifferentiation or mucinous component at the invasive margin (unfavorable histology). RESULTS: Multivariate logistic regression analysis revealed that both sex and unfavorable histology were significantly associated with LNM (P = 0.0102, 0.0226, respectively). However, the associations between LNM and lymphatic invasion or tumor location were not statistically significant (P = 0.0947, 0.1738). CONCLUSIONS: When locally resected T2 rectal carcinoma specimens have unfavorable histology at the invasive margin, additional bowel resection with lymph node dissection should be recommended.