Differing relationship between hypercholesterolemia and a bicuspid aortic valve according to the presence of aortic valve stenosis or aortic valve regurgitation.

OBJECTIVES: To assess the difference in hyperlipidemia between patients with bicuspid aortic valve (BAV) and those with a normal aortic valve (NAV), and to compare aortic valve stenosis (AS), with aortic valve regurgitation (AR). METHODS: Among 32 patients with BAV and 142 patients with NAV who underwent aortic valve replacement, 81 patients had AR and 91 patients had AS. The preoperative clinical characteristics were compared between the BAV and NAV patients. Patients with replacement of the ascending aorta were included, and those who underwent combined valvular surgery, coronary artery bypass grafting, or statin treatment were excluded. RESULTS: The proportions of females patients (p = 0.42), patients with diabetes (p = 0.26) and patients on dialysis (p = 0.69) were similar in the two groups. Mean age was significantly lower, the mean diameter of the ascending aorta was significantly larger, and the rate of surgical intervention for the ascending aorta was significantly higher in the BAV group than in the NAV group (all p < 0.0001). The mean levels of low-density lipoprotein cholesterol (LDL) (p < 0.0001) and total cholesterol (TC) (p = 0.0003) were significantly higher in the BAV group than in the NAV group, in the analysis of only patients with AS, whereas these levels did not differ significantly between the groups, when only patients with AR were considered. CONCLUSION: BAV with AS is associated with hypercholesterolemia. However, BAV with AR was not associated with hypercholesterolemia.

Minimally invasive direct coronary artery bypass surgery with right gastroepiploic artery for redo patients.

Coronary artery bypass grafting (CABG) has been widely performed for coronary artery disease. Therefore, cases requiring reoperative CABG are increasing. We performed a minimally invasive direct coronary artery bypass (MIDCAB) procedure on four patients, as reoperative CABG surgery for the right coronary artery (RCA), employing the right gastroepiploic artery (RGEA). The target sites were the distal RCA in two patients and the posterior descending (PD) branch in the other two. Complete revascularization was accomplished in all patients without sternotomy, cardiopulmonary bypass (CPB), or blood transfusion. The mean operative time was 3.0 h (range: 2.4-3.7 h). Postoperative coronary angiography showed all grafts to be patent. All patients were discharged without postoperative complications and remained free from cardiac events during a mean follow-up period of 1.5 years (range: 0.5-3.0 years). MIDCAB for the RCA, employing the RGEA via a subxiphoid incision showed, excellent revascularization in redo CABG cases. This technique is a safe and effective method for redo cases.

[Familial Annulo-aortic Ectasia without Marfan Syndrome].

Marfan syndrome is a hereditary disease that presents ocular, skeletal, and cardiovascular abnormalities. In recent years, there have been several reports of patients with familial cardiovascular disease but no physical features of Marfan syndrome. We encountered 3 cases of familial annulo-aortic ectasia (AAE). Their father had also had aortic regurgitation, and died during surgery 10 years before. No case demonstrated any physical characteristics of Marfan syndrome or any other connective tissue disease. All cases were operated successfully. One case showed cystic medial necrosis, and 2 cases showed degenerative change. The present report suggests that familial AAE may be caused by weakness of the aortic wall related to heredity. If AAE is left untreated, it can lead to aortic dissection. Thus, we recommend that patients with familial AAE should undergo screening and follow-up similar to patients with Marfan syndrome.

[Redo double valve replacement in a patient with bioprosthetic valve malfunction by pannus formation; report of a case].

A 76-year-old female, who had received Carpentier-Edwards perimount (CEP) pericardial bioprostheses for aortic and mitral valves 6 years before, was diagnosed with reduced mobility of the valvular cusps by echocardiogram 2 years after the surgery. The symptoms of heart failure gradually aggravated. Significant stenosis and regurgitation were observed of the prosthetic valves, and a second surgery was performed. Calcification and severe pannnus formation were observed of both CEP valves that were excised.

[A case of advanced esophagogastric junction cancer responding to pre-operative combination chemotherapy of docetaxel, cisplatin, S-1, and trastuzumab].

We have no consensus on surgical treatment and chemotherapy for esophagogastric junction cancer in Japan. A 51-yearold man reporting dysphagia was examined, and through upper gastrointestinal endoscopy was found to have a tumor at the esophagogastric junction. Histologically, biopsy specimens indicated adenocarcinoma with genetic amplification of human epidermal growth factor receptor type 2(HER2). Positron emission tomography showed swelling of several abdominal lymph nodes with accumulation of fluorodeoxyglucose. He was treated with esophagogastorectomy with left thoracotomy after combination chemotherapy of docetaxel, cisplatin, S-1, and trastuzumab. He had no complication from the operation and had no adverse effect from the combination chemotherapy. Histopathological examination of the resected specimen showed a minute residual cancer nest at the muscularis propria of the esophagus, but no lymph node metastasis. This regimen could be useful for advanced junctional cancer with HER2 amplification as preoperative chemotherapy.

[A case of multiple distant lymph node metastases from advanced gastric cancer treated with adjuvant chemotherapy after total gastrectomy].

A 70-year-old woman with advanced gastric cancer (U, type 3, por, pT3, ly3, v2, pN3a [10/92, No. 1, 3], Stage IIIB) underwent total gastrectomy and D2 dissection followed by adjuvant chemotherapy with S-1. Eight months later, computed tomography (CT) showed multiple distant lymph node metastases, including metastases in the para-aortic and supraclavicular( Virchow's nodes) lymph nodes. Chemotherapy with cisplatin( CDDP) and irinotecan( CPT-11) was administered with concurrent radiation therapy for the para-aortic nodes. After 2 courses, the para-aortic lymph nodes showed complete response( CR), but Virchow's nodes showed partial response( PR). Dissection of Virchow's nodes was performed. Histopathological examination revealed a chemotherapeutic effect on the dissected node, and therefore, 2 more courses of chemotherapy were administered after the operation. Adverse events such as grade 3 neutropenia and grade 4 hyponatremia were observed. At present, the patient is well without recurrence, and chemotherapy is not being administered. Local therapy for distant metastasis followed by systemic chemotherapy may have been effective in this case.

Laparoscopic introduction of a center rod using a Nelaton catheter during laparoscopic esophagogastrostomy.

During laparoscopic proximal gasterctomy, the difficulty associated with the use of a circular stapler for esophagogastrectomy is not only the fixation of the anvil, but also the laparoscopic manipulation of the body of the circular stapler. We have developed a new approach to the laparoscopic introduction of the center rod using a Nelaton catheter. After transection of the esophagus, the stomach is pulled out through an umbilical minilaparotomy. The proximal gastrectomy is performed extracorporeally, and a Nelaton catheter is passed through a small incision at the lower body of the stomach and a small penetrating wound at the point of the esophagogastrostomy. The Nelaton catheter is attached to the center rod of the circular stapler. The center rod can be guided to the appropriate point laparoscopically by the Nelaton catheter. Between January 2009 and May 2010, 11 patients underwent this procedure, successfully. This technique was useful for laparoscopic proximal gastrectomy.

Laparoscopic-assisted low and ultralow anterior resection for lower rectal cancer using the simple "Rectum Catcher" device and an intra-operative colonoscopy.

PURPOSE: We report the feasible technique in lower rectal surgery. MATERIALS AND METHODS: The Rectum Catcher (Matsumoto et al. in Surg Endosc 22:1905-1909, 2008) is made of stainless steel, with a circle of diameter 6 mm punched out at a distance of 5 mm from the top and covered with a short-cut T-tube. A vessel tape is inserted into the stainless steel and the short-cut T-tube. The rectum is grasped using the Rectum Catcher at a proximal rectum of the cancer, and the location of the cancer is confirmed using an intra-operative colonoscopy. In the next step, the Rectum Catcher is applied at the distal rectum of the cancer, and which easily occludes the rectum, and we confirm that the cancer is not at the distal rectum from the Rectum Catcher, using an intra-operative colonoscopy. The rectal lumen is irrigated. Then, the linear cutter is positioned just distal rectum to the Rectum Catcher, and the rectum is transected adequately. RESULTS: From January 2009 to the present, this study included 18 patients undergoing laparoscopic-assisted low and ultralow anterior resection for lower rectal cancer, using the Rectum Catcher and an intra-operative colonoscopy. Using the Rectum Catcher and an intra-operative colonoscopy, we can easily make a decision of the location of rectal cancer in lower rectum and irrigation of rectal lumen can be easily performed to safely cut the bowel being occluded, in the narrow laparoscopic view of the pelvic cavity. CONCLUSION: The combination between the Rectum Catcher and an intra-operative colonoscopy is useful for performing laparoscopic rectal surgery.

[A case of recurrent breast carcinoma metastasis successfully treated with S-1 and zoledronic acid therapy].

We experienced a case of triple-negative recurrent breast carcinoma achieving a significant improvement by oral S- 1, a fluoropyrimidine-class anticancer drug and zoledronic acid(ZOL), a third generation bisphosphonate(BP). / Against metastases to orbital foramen, chest wall and bone, the oral treatment with S-1 was started at 80 mg/day everyday for 4 weeks, followed by a 2-week rest interval as 1 cycle, and ZOL was injected at 4 mg every 4 weeks. After 2 cycles of treatment, the level of tumor markers and tumor sizes became reduced. Twelve cycles after the initiation of the therapy, recrudescence of the metastatic lesions was not recognized, and no other metastases were recognized in any organ. In the course of the treatment, no adverse drug reactions to S-1 occurred in the patient. For treatment of recurrent breast carcinoma, S-1 is considered to be a useful and tolerable anticancer drug, and combination treatment of S-1 and ZOL is thought to be effective.

The simple "Rectum Catcher" device is a useful tool for laparoscopic-assisted high and lower rectal surgery.

BACKGROUND: This report describes our experience in 13 patients with rectal cancer along with a general overview of the use of the simple "Rectum Catcher" device in high and lower rectal surgery. MATERIALS AND METHODS: The Rectum Catcher is made of stainless steel (length 40 cm, caliber 7 mm), with a circle of diameter 6 mm punched out at a distance of 5 mm from the top and covered with a short-cut T-tube (length 1 cm, caliber 6 mm) (SILKOLATEX T-tube, 8 mm; Willy Rusch AG, Germany). A vessel tape (width 9 mm, length 120 cm; Kawano Seisakusho, Chiba, Japan) is inserted into the stainless steel and the short-cut T-tube. The Rectum Catcher is inserted into the abdominal cavity through the 12-mm trocar (Ethicon Endo Surgery) and a vessel tape is circled the rectum and pulled to catch it. Thirteen patients with rectal cancer were operated laparoscopically using the Rectum Catcher at our hospital. RESULTS: From January 2007 to the present, this study included 13 patients (5 men and 8 women) undergoing laparoscopic-assisted high anterior resection (Lap-HAR, five patients), low anterior resection (Lap-LAR: six patients), and abdominoperineal resection (Lap-APR: two patients) for rectal cancer, using the Rectum Catcher. Using the Rectum Catcher, easy maneuverability of the rectum and irrigation of rectal lumen can be easily performed to safely cut the bowel being occluded, in the narrow laparoscopic view of the pelvic cavity. CONCLUSION: In our experience, the simple Rectum Catcher device is safe and useful for performing laparoscopic assisted high and lower rectal surgery.

Prognostic significance of gastric cancer metastasis in second-tier lymph nodes detected on reverse transcriptase-polymerase chain reaction and immunohistochemistry.

To determine the prognostic significance of the methods used to determine the presence of metastasis in second-tier lymph nodes of patients with gastric cancer, the authors studied lymph nodes surgically removed from 100 patients with gastric cancer (55 with early cancer, 45 with progressive). The results of HE staining were compared with those of immunohistochemistry using the anticytokeratin (CK) antibody and reverse transcriptase-polymerase chain reaction (RT-PCR) assays. Lymph node 7 or 8a was obtained intraoperatively, then mRNA was extracted using an immunobeads method, and RT-PCR with CK19 mRNA was performed. The P for Cox regression analysis for metastasis detected by HE staining, CK staining, and RT-PCR of all 100 cases was 0.312, 0.426, and 0.021, respectively, while for second-tier lymph nodes it was 0.154, 0.013, and 0.006, respectively. In conclusion, RT-PCR and CK staining for detection of metastasis in second-tier lymph nodes were more reliable prognostic indicators than conventional HE staining.

Laparoscopy-assisted esophagoenteral anastomosis using endoscopic purse-string suture instrument "Endo-PSI (II)" and circular stapler.

It is said that laparoscopic esophagoenteral anastomosis is not easy. In particular, purse-string suture of the abdominal esophagus is difficult when using a circular stapler. We have developed an endoscopic purse-string suture instrument, the "Endo-PSI (II)", and the instrument was employed clinically during laparoscopy-assisted total gastrectomy. The device was inserted into the abdominal cavity through a 4-cm minilaparotomy of the epigastrium, and pneumoperitoneum was established by closing a Lap Disc. The Endo-PSI (II) was attached to the abdominal esophagus and a straight needle with a 2-0 polypropylene suture was passed through the device laparoscopically. After a purse-string suture of the abdominal esophagus was made, the abdominal esophagus was transected laparoscopically and the removed stomach was pulled out through the minilaparotomy. The anvil head of a circular stapler was inserted into the abdominal cavity through the minilaparotomy, and insertion of the anvil into the esophagus and ligation of the purse-string suture were performed laparoscopically, too. The combination of using a circular stapler for esophagojejunostomy and closure of the jejunal stump was also performed laparoscopically. Between May 2007 and May 2008, these products were used in 23 patients during laparoscopy-assisted total gastrectomy. There were no cases that required conversion to a conventional open procedure. The newly developed Endo-PSI (II) was useful for laparoscopic purse-string suture of the esophagus.

Amelioration of hepatic ischemia/reperfusion injury in the remnant liver after partial hepatectomy in rats.

BACKGROUND AND AIMS: Reactive oxygen species have been implicated in the development of hepatic ischemia/reperfusion (I/R) injury. I/R injury remains an important problem in massive hepatectomy and organ transplantation. The aim of this study was to examine the effect of edaravone, a newly synthesized free radical scavenger, on I/R injury in the remnant liver after partial hepatectomy in rats. METHODS: Partial (70%) hepatic ischemia was induced in rats by occluding the hepatic artery, portal vein, and bile duct to left and median lobes of liver. Total hepatic ischemia (Pringle maneuver) was induced by occluding the hepatoduodenal ligament. Edaravone was intravenously administered to rats just before reperfusion and partial (70%) hepatectomy was performed just after reperfusion. RESULTS: Edaravone significantly reduced the increases in the levels of serum alanine aminotransferase and aspartate aminotransferase in rats with liver injury induced by 90-min of partial ischemia followed by 120-min of reperfusion. Histopathological analysis showed that edaravone prevented inflammatory changes in the livers with I/R injury. Edaravone also decreased the levels of myeloperoxidase activity, which is an index of neutrophil infiltration, and interleukin-6 mRNA, which is a proinflammatory cytokine. Additionally, edaravone improved the survival rate in partial hepatectomy rats with I/R injury induced by the Pringle maneuver. CONCLUSIONS: Edaravone administration prior to reperfusion protected the liver against I/R injury. Edaravone also improved the function of the remnant liver with I/R injury after partial hepatectomy. Therefore, edaravone may have applicability for major hepatectomy and liver transplantation in the clinical setting.

Hand-assisted laparoscopic esophagojejunostomy using newly developed purse-string suture instrument "Endo-PSI".

Although there are several reports on the esophagojejunostomy during laparoscopy-assisted total gastrectomy, the procedures still remain to be established. We report hand-assisted laparoscopic esophagojejunostomy using circular stapler and newly developed instrument "Endo-PSI." Between April 2005 and April 2006, 13 patients received these products during laparoscopy-assisted total gastrectomy. The Endo-PSI was attached to the abdominal esophagus using hand-assisted laparoscopic surgery. The insertion of the straight needle with 2-0 polypropylene into the device and the cutting of the esophagus were also performed using hand-assisted laparoscopic surgery. The insertion of the anvil head into the esophagus and the ligation of the purse-string suture were performed laparoscopically. After the jejuno-jejunal anastomosis was performed extracorporeally, the combination of the circular stapler for esophagojejunostomy and the closure of the stump of the jejunum were performed laparoscopically. There were no complications attributable to this procedure and there were no cases that required conversion to conventional open procedure or required extension of median incision. This newly developed Endo-PSI was useful for laparoscopic purse-string suture.

Oral rehydration solution for providing water and electrolytes following laparoscopic cholecystectomy and recovery of intestinal function.

BACKGROUND/AIMS: Oral rehydration solution (OS-1: Na+ 50mEq/L, K+ 20mEq/L, Cl- 50mEq/L, and glucose 1.8%) was administered orally to patients from the early phase following laparoscopic cholecystectomy to assess its effects on water and electrolyte supplementation and recovery from postoperative intestinal paralysis. METHODOLOGY: OS-1 group (n = 22) received OS-1 orally and KN3B group (n = 22) received KN3B (an intravenous maintenance solution) intravenously. The OS-1 group was instructed to consume approximately 1000-1500mL of OS-1 postoperatively from as soon as oral intake was possible up to before lunch on postoperative day 1. RESULTS: The average dose in the OS-1 group (1178 +/- 319 mL) was significantly lower than that in the KN3B group (1371 +/- 196 mL), but within the target dose. The two solutions were equally effective and safe for water and electrolyte supplementation. The time for 50% of patients to pass bowel gas after surgery (indicating recovery from intestinal paralysis) was significantly shorter in the OS-1 group (14.00 hours) than in the KN3B group (23.75 hours). CONCLUSIONS: Oral rehydration solution (OS-1), administered from the early postoperative phase, is safe and effective for the provision of water and electrolytes and promotes early recovery from intestinal paralysis as assessed by the passage of bowel gas following laparoscopic cholecystectomy.

Laparoscopy-assisted total gastrectomy for early gastric cancer: comparison with conventional open total gastrectomy.

Laparoscopy-assisted distal gastrectomy has been applied to the treatment of early gastric cancer in Japan. So far, several studies about comparison between laparoscopy-assisted distal gastrectomy and conventional open distal gastrectomy were reported. However, there are few reports on the laparoscopy-assisted total gastrectomy, mainly because this procedure is performed relatively infrequently, and the procedure is more difficult than laparoscopy-assisted distal gastrectomy. This was a case-control study comparing between laparoscopy-assisted total gastrectomy group and open total gastrectomy group. From June 2001 to August 2004, laparoscopy-assisted total gastrectomy was performed in 20 patients. Reconstruction was performed by Roux-en-Y method or Roux-en-Y with jejunal pouch method through the mini-laparotomy. These cases were compared with 19 cases of open total gastrectomy, regarding operating time, blood loss, leukocyte count, C-reactive protein, time to the first passage of gas, time to initiate oral intake, and postoperative hospital stay.Laparoscopy-assisted total gastrectomy was successful in 20 patients. The mean operating time was 280 minutes and blood loss was 227.5 mL. Leukocyte counts on days 1, 3, and 7 were significantly lower in laparoscopic surgery group than in open surgery group. The time to first flatus, time to initiate oral intake, and postoperative hospital stay was significantly shorter (P < 0.05) in the laparoscopic surgery group than in the open surgery group. This study demonstrated that laparoscopy-assisted total gastrectomy is suitable and feasible for early gastric cancer and has the advantage of a shorter recovery time compared with open total gastrectomy.

Preoperative imaging of surrounding arteries by three-dimensional CT: is it useful for laparoscopic gastrectomy?

One of the difficulties in laparoscopic gastrectomy is the identification of the feeding artery of the stomach. Recently, 3-dimensional computed tomographic angiography has enabled the noninvasive visualization of arteries surrounding the stomach. Preoperative 3-dimensional computed tomographic angiography may facilitate laparoscopic gastrectomy by obtaining a road map of the arteries of the stomach. Twenty-nine cases of gastric cancer were evaluated using 3-dimensional computed tomographic angiography before surgery. Three-dimensional computed tomographic angiography showed the left gastric artery in 29 patients (100%), the right gastroepiploic artery in 29 patients (100%), the right gastric artery in 24 patients (82.8%), and the left gastroepiploic artery in 21 patients (72.4%). The aberrant hepatic artery was detected in 6 patients, and the variant of the right gastric artery and the variant of the left gastric artery were detected in 5 cases and 1 case, respectively. All laparoscopic gastrectomy procedures were performed successfully without conversion to open surgery. Preoperative 3-dimensional computed tomographic angiography was considered to be useful for laparoscopic gastrectomy.

Expression of homeodomain protein CDX2 in gallbladder carcinomas.

PURPOSE: Caudal-related homeobox protein CDX2 plays an important role in the regulation of cell proliferation and differentiation of the intestinal epithelium. CDX2 is associated with intestinal metaplasia and carcinomas of the stomach, but the role of CDX2 in gallbladder carcinogenesis remains unknown. METHODS: We analyzed the expression of CDX2 and intestinal apomucin MUC2 in gallbladder cancer cell lines at the mRNA level by the RT-PCR method. We also investigated the expression of CDX2 and MUC2 in 68 primary gallbladder carcinomas by the immunohistochemical staining method and compared the expression of CDX2 with the clinicopathological factors in the gallbladder carcinoma cases. RESULTS: Expression of CDX2 and MUC2 was found in three of four gallbladder cancer cell lines at the mRNA level. In addition, we found that CDX2 was absent in the normal gallbladder epithelium, but the CDX2 protein was expressed in 25 of the 68 (36.8%) gallbladder carcinomas. Interestingly, in the tubular type gallbladder carcinomas, the frequency of CDX2 expression was much higher in the well-differentiated type than the moderately and poorly differentiated types, the difference being statistically significant (P<0.01). CDX2 expression showed a relationship with expression of MUC2 (P<0.04) in the gallbladder carcinomas. CDX2 was expressed in intestinal metaplasia and dysplasia, which are hypothesized to be premalignant conditions. CONCLUSION: These results imply that CDX2 plays an important role in gallbladder carcinogenesis with intestinal differentiation.

SOFA score predicts postoperative outcome of patients with colorectal perforation.

BACKGROUND/AIMS: Colorectal perforation remains a life-threatening condition associated with high mortality. Various factors and operative procedures have been discussed in regard to prediction of outcome, and several scoring systems have been proposed to predict the outcome of critically ill patients. The present study was undertaken to identify factors and determine predictive scoring systems for the postoperative outcome of patients with colorectal perforation. METHODOLOGY: Between January 1996 and December 2000, 45 consecutive patients underwent emergency operation for colorectal perforation. Twelve patients (26.7%) died in hospital. The correlation of outcome with various preoperative factors, APACHE II and SOFA scores were assessed retrospectively. RESULTS: Univariate analysis showed that outcome was significantly related to maximum SOFA score (p=0.0069). Multivariate logistic regression analysis demonstrated that the maximum SOFA score was an independent predictor (p=0.016). Serum creatinine level (p=0.013) and platelet count (p=0.036) were associated with patient outcome in the SOFA score. Patients with a SOFA score higher than 7 had a greater risk of hospital death (p=0.0085). CONCLUSIONS: The maximum postoperative SOFA score is a useful predictor of the outcome from surgery for colorectal perforation.