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An upside-down stomach is a rare type of hiatal hernia. An 83-year-old woman presented to the emergency room with abdominal pain and vomiting. Computed tomography revealed an upside-down stomach and the incarceration of a part of the gastric body into the abdominal cavity. Upper gastrointestinal endoscopy revealed a circular ulcer caused by gastric ischemia. Although she was discharged after 1 week of conservative therapy, she was readmitted to the hospital 1 day after discharge because of a recurrence of hiatal hernia incarceration. She underwent laparoscopic surgery 4 days after readmission and recovered successfully.
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Introduction: The systemic inflammatory score (SIS), a new inflammatory marker based on a combination of the lymphocyte-to-monocyte ratio (LMR) and serum albumin concentration, has been reported to be a useful prognostic marker for several malignancies. The authors conducted this retrospective study on data from a cohort of esophageal cancer patients undergoing potentially curative resection to clarify the value of SIS as a prognostic marker for clinical outcome in this population. Methods: This retrospective cohort study included 32 patients who underwent thoracoscopic esophagectomy after neoadjuvant chemotherapy for esophageal cancer between January 2016 and December 2019. Blood samples were collected within one week prior to the initiation of preoperative chemotherapy. Three inflammatory and nutritional markers; SIS, the neutrophil-to-lymphocyte ratio (NLR), and prognostic nutrition index (PNI) were examined in this study. Disease-free survival was assessed using the Kaplan-Meier method, and univariable and multivariable Cox models were applied to evaluate the predictive value of SIS, NLR and PNI. Results: NLR and PNI were not associated with recurrence, while SIS scores of 1 and 2 were significantly associated with recurrence. In multivariate analysis, SIS scores of 1 or 2 were found to be independently associated with recurrence, each with a hazard ratio of 1.98. In addition, when examining immunologic and nutritional factors and survival rates, there was no significant difference in the survival rate for NLR and PNI; for SIS, however, the survival rate was significantly worse in patients with SIS scores of 1 or 2. Conclusions: The authors demonstrated that a novel and easily obtained prognostic score, termed SIS, based on pre-treatment serum albumin and LMR, can serve as an independent prognostic factor in postoperative esophageal cancer patients. It could be incorporated into conventional clinical and pathological algorithms to enhance the prognostic accuracy in this population.
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Introduction: Primary malignant melanoma of the esophagus is a very rare disease with a poor prognosis. We herein report a patient with primary malignant melanoma of the esophagus who underwent surgical resection. Case Presentation: A 73-year-old female underwent an upper gastrointestinal endoscopy during follow-up for colonic diverticulitis. An endoscopic examination and constructed radiography revealed a slightly elevated black pigmented lesion in the upper esophagus and a black pigmented area in the esophagogastric junction. Through a preoperative endoscopic biopsy, she was diagnosed with malignant melanoma of the esophagus. We performed thoracoscopy-assisted and laparoscopy-assisted subtotal esophagectomy with lymphadenectomy. The surgical specimens were subjected to immunohistochemical analysis, resulting in a diagnosis of malignant melanoma. The tumor cells were positive for Melan-A and HMB-45 diffusely, supporting that diagnosis. We performed surgical resection in a case of primary malignant melanoma of the esophagus, and the patient has remained disease free for 2 years since the surgery. Conclusion: Early diagnosis and radical resection may be essential for long-term survival in patients with malignant melanoma of the esophagus.
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Juxta-articular myxoma (JAM) is a rare soft tissue tumour predominantly composed of mucinous tissue and usually found around large joints. We report a 73-year-old woman with a 5-year history of a soft tissue mass in the thenar eminence of the right wrist who presented to our department. An initial diagnosis of a ganglion cyst was made using magnetic resonance imaging (MRI) and the jellied content of the mass by aspiration. Two years after presentation, surgical treatment with tumour resection and carpal tunnel release via the radial approach was performed because the symptoms of carpal tunnel syndrome worsened, and the tumour invaded the carpal tunnel. Histopathological examination revealed a JAM. At the 1-year follow-up, the symptoms of carpal tunnel syndrome had resolved, and no recurrence was confirmed by MRI. Level of Evidence: Level V (Therapeutic).
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Síndrome del Túnel Carpiano , Mixoma , Neoplasias de los Tejidos Blandos , Femenino , Humanos , Anciano , Síndrome del Túnel Carpiano/diagnóstico por imagen , Síndrome del Túnel Carpiano/etiología , Muñeca/cirugía , Mano , Neoplasias de los Tejidos Blandos/cirugía , Mixoma/diagnóstico , Mixoma/diagnóstico por imagenRESUMEN
Liver metastasis in gastric cancer is incurable. Alpha-fetoprotein-producing gastric cancer has a poor prognosis and is prone to liver metastasis. We investigated the association between preoperative serum alpha-fetoprotein levels, liver metastasis, and expression of primitive enterocyte phenotype markers. We reviewed the medical records of 401 patients with gastric cancer who underwent curative surgical resection and immunohistochemically evaluated the primitive phenotype markers. The preoperative serum alpha-fetoprotein levels were elevated and normal in 8 and 393 patients, respectively. Liver metastasis was more frequent in patients with higher preoperative alpha-fetoprotein levels. The 5-year postoperative recurrence-free survival and overall survival rates were significantly worse in patients with higher preoperative serum alpha-fetoprotein levels. Although alpha-fetoprotein and Glypican3 and Spalt-like transcription factor 4 tended to be stained with high preoperative serum alpha-fetoprotein levels, these markers were also positive in some patients with normal alpha-fetoprotein levels. In summary, patients with gastric cancer and high preoperative serum alpha-fetoprotein levels have a poor prognosis and high incidence of liver metastasis. Alpha-fetoprotein can help detect liver metastasis relating to the primitive enterocyte phenotype.
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Neoplasias Hepáticas , Neoplasias Gástricas , Humanos , alfa-Fetoproteínas/metabolismo , Neoplasias Gástricas/patología , Inmunohistoquímica , Pronóstico , Neoplasias Hepáticas/cirugíaRESUMEN
Objective: Gastric pull-up is a common procedure to reconstruct the continuity of the upper digestive tract after esophagectomy. However, this technique sometimes causes postoperative anastomotic leakage or stricture, resulting from congestion of the gastric tube. We performed additional microvascular venous anastomoses to solve this problem. The purpose of this study was to compare postoperative anastomotic leaks and strictures in cases with or without additional venous superdrainage after gastric tube reconstruction. Methods: A total of 117 consecutive patients with cervical and thoracic esophageal cancer who underwent thoracoscopic esophagectomy with gastric tube reconstruction in the National Nagasaki Medical Center between 2011 and 2021 were analyzed retrospectively. Of these patients, 46 did not undergo additional venous anastomoses (standard group), and 71 who underwent gastric pull-up surgery after November 2014 have added this surgical procedure to their routine (superdrainage group). We compared the frequency of postsurgical leakage and stricture in the 2 groups retrospectively. Results: Fifteen patients (32.6%) developed postoperative leakage in the standard group and 6 (8.5%) did so in the superdrainage group. Twelve patients (26.1%) showed postoperative anastomotic stricture in the standard group and 7 (9.9%) did so in the superdrainage group. Patients who did not undergo additional venous superdrainage were significantly more likely to develop postsurgical leakage (χ2 test P < .01) and anastomotic stricture (χ2 test P < .05). The mean time taken to perform additional venous anastomoses was 54.2 minutes. Conclusions: Our study revealed that performing additional venous anastomosis for as little as 1 hour can significantly reduce the incidence of postoperative leakage and stenosis. This procedure is of merit to perform after total esophagectomy with gastric tube reconstruction.
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Diospyrobezoar is a relatively uncommon cause of small bowel obstruction. Here we report successful treatment in a patient with small bowel obstruction due to diospyrobezoar by laparoscopic-assisted surgery. A 93-year-old woman who had undergone distal gastrectomy and laparoscopic cholecystectomy presented with nausea and anorexia. An intestinal obstruction and an intestinal intraluminal mass were discovered on abdominal enhanced computed tomography. Following a transnasal ileus tube placement, the patient underwent laparoscopic surgery to remove the diospyrobezoar from the small intestine. The postoperative course of the patient was uneventful. Laparoscopic-assisted surgery following the transnasal ileus tube was beneficial for the patient's small bowel obstruction caused by diospyrobezoar.
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Ileus , Obstrucción Intestinal , Laparoscopía , Femenino , Humanos , Anciano de 80 o más Años , Obstrucción Intestinal/diagnóstico por imagen , Obstrucción Intestinal/etiología , Obstrucción Intestinal/cirugía , Laparoscopía/efectos adversos , Laparoscopía/métodos , Ileus/etiología , Ileus/cirugía , Colecistectomía/efectos adversos , Gastrectomía/efectos adversosRESUMEN
BACKGROUND: Postoperative complications related to gastric conduit reconstruction are still common issues after McKeown esophagectomy. A novel endoscopic mucosal ischemic index is desired to predict anastomotic complications after McKeown esophagectomy. AIMS AND METHODS: The purpose of this study was to prospectively evaluate the safety and efficacy of endoscopic examinations of the anastomotic region in the acute period after esophagectomy. Endoscopic examinations were performed on postoperative days (PODs) 1 and 8. The severity of ischemia was prospectively validated according to the endoscopic mucosal ischemic index (EMII). RESULTS: A total of 58 patients were included after evaluating the safety and feasibility of the endoscopic examination on POD 1 in 10 patients. Anastomotic leakage occurred in 6 patients. Stricture occurred in 13 patients. A greater than 67% circumference and lesion length greater than 20 mm of anastomotic ischemic area (AIA) on POD 1 were associated with developing anastomotic leakage after esophagectomy (OR: 14.5; 95% CI: 1.8-306.5; P = 0.03, OR: 19.4; 95% CI: 1.7-536.8; P = 0.03). More than 67% circumferential ischemic mucosa and ischemic mucosal lengths greater than 20 mm of AIA on POD 1 were associated with developing anastomotic strictures after esophagectomy (OR: 6.4; 95% CI: 1.4-31.7; P = 0.02, OR: 5.9; 95% CI: 1.2-33.1; P = 0.03). Patients with either more than 67% circumferential ischemic mucosa or ischemic mucosal lengths greater than 20 mm of AIA on POD 1 were defined as EMII-positive patients. The sensitivity, specificity, and positive and negative predictive values of EMII positivity on POD 1 for leakage were 100%, 78.8%, 35.3%, and 100%, respectively. The sensitivity, specificity, and positive and negative predictive values of the EMII positivity on POD 1 for strictures were 69.2%, 82.2%, 52.9%, and 90.2%, respectively. CONCLUSIONS: The application of an endoscopic classification system to mucosal ischemia after McKeown esophagectomy is both appropriate and satisfactory in predicting anastomotic complications. TRIAL REGISTRATION: Clinical Trial.gov Registry, ID: NCT02937389, Registration date: Oct 17, 2015.
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Neoplasias Esofágicas , Esofagectomía , Humanos , Anastomosis Quirúrgica/efectos adversos , Fuga Anastomótica/diagnóstico , Fuga Anastomótica/epidemiología , Fuga Anastomótica/etiología , Constricción Patológica/cirugía , Neoplasias Esofágicas/cirugía , Esofagectomía/efectos adversos , Isquemia/etiología , Isquemia/cirugía , Membrana Mucosa/patología , Membrana Mucosa/cirugía , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
We describe a case of pancreatic tumor associated with a giant type IV hiatal hernia that had prolapsed into the posterior mediastinum. Hiatal hernia repair should be performed first because it enables laparoscopic distal pancreatectomy to be performed in the normal anatomical position.
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INTRODUCTION: Situs inversus totalis (SIT) is a congenital anatomical variant in which organs and vasculature are positioned in a mirror-image relationship to the normal condition. Therefore, the surgical procedures need to be carefully planned with these factors in mind. CASE PRESENTATION: A 57-year-old man with SIT was diagnosed with a hepatocellular carcinoma (HCC) and was planned for caudate lobectomy. As preoperative preparation, 3D reconstructed images were created based on the contrast-enhanced CT images, and careful simulations were performed on the vascular anomalies and location of the tumor. There was a replaced left hepatic artery forming a common trunk with a left gastric artery. In addition, using media player software, a previous caudate lobectomy video was played in right and left inverted mode to simulate the abdominal surgical field image in SIT. The operative time was 285 min, and the blood loss was 440 ml. The preoperative careful simulation allowed us to proceed with the surgery without significant discomfort. CONCLUSION: Even in the case of hepatocellular carcinoma with SIT, hepatectomy for hepatocellular carcinoma can be safely performed by careful preoperative simulations.
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The aim of this study was to determine the efficacy and the biomarkers of the CHP-NY-ESO-1 vaccine complexed with full-length NY-ESO-1 protein and a cholesteryl pullulan (CHP) in patients with esophageal squamous cell carcinoma (ESCC) after surgery. We conducted a randomized phase II trial. Fifty-four patients with NY-ESO-1-expressing ESCC who underwent radical surgery following cisplatin/5-fluorouracil-based neoadjuvant chemotherapy were assigned to receive either CHP-NY-ESO-1 vaccination or observation as control. Six doses of CHP-NY-ESO-1 were administered subcutaneously once every two weeks, followed by nine more doses once every four weeks. The endpoints were disease-free survival (DFS) and safety. Exploratory analysis of tumor tissues using gene-expression profiles was also performed to seek the biomarker. As there were no serious adverse events in 27 vaccinated patients, we verified the safety of the vaccine. DFS in 2 years were 56.0% and 58.3% in the vaccine arm and in the control, respectively. Twenty-four of 25 patients showed NY-ESO-1-specific IgG responses after vaccination. Analysis of intra-cohort correlations among vaccinated patients revealed that 5% or greater expression of NY-ESO-1 was a favorable factor. Comprehensive analysis of gene expression profiles revealed that the expression of the gene encoding polymeric immunoglobulin receptor (PIGR) in tumors had a significantly favorable impact on outcomes in the vaccinated cohort. The high PIGR-expressing tumors that had higher NY-ESO-1-specific IgA response tended to have favorable prognosis. These results suggest that PIGR would play a major role in tumor immunity in an antigen-specific manner during NY-ESO-1 vaccinations. The IgA response may be relevant.
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Vacunas contra el Cáncer , Neoplasias Esofágicas , Carcinoma de Células Escamosas de Esófago , Receptores de Inmunoglobulina Polimérica , Anticuerpos Antineoplásicos , Antígenos de Neoplasias , Cisplatino , Carcinoma de Células Escamosas de Esófago/tratamiento farmacológico , Fluorouracilo , Glucanos , Humanos , Inmunoglobulina A , Inmunoglobulina G , Proteínas de la Membrana , PronósticoRESUMEN
Infection of urachal remnant may cause recurrent abscesses. In the current case report, we describe a urachal remnant infection leading to a retroperitoneal abscess, which is an extremely rare condition. In such cases, the recommended treatment is urachal remnant resection.
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Esophageal carcinosarcoma is a rare malignant tumor composed of both carcinomatous and sarcomatous elements. We report a case of esophageal carcinosarcoma in a 56-year-old woman with dysphagia. Esophageal ulcerative tumors were detected by endoscopy and resected by thoracoscopic esophagectomy. Carcinosarcoma was confirmed by the presence of both carcinomatous and sarcomatous tumor components. On immunohistochemistry, the sarcomatous area was positive for keratin staining, while the sarcomatous area was positive for vimentin staining. The tumor reportedly had a better prognosis than SCC of the esophagus, especially in terms of survival rate. The patient's disease was classified as ypT3N0M0, ypStage II. No definitive diagnosis was made preoperatively. We report this case along with a review of the literature.
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Acute mesenteric ischemia (AMI) is often caused by superior mesenteric artery (SMA) embolization. We report a rare case of synchronous celiac axis and SMA embolization in an elderly woman with initially mild abdominal pain. Ultimately, a second contrast-enhanced computed tomography revealed extensive necrosis from the stomach to the transverse colon together with liver ischemia due to hours of occlusion. Multiorgan failure made palliation the only option, and she died the following evening. Autopsy revealed a fragile atherosclerosis-asso-ciated thrombus. Careful examination and repeat diagnostic tests should be performed in patients with mild abdominal symptoms at risk for AMI.
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Oclusión Vascular Mesentérica/diagnóstico , Abdomen Agudo/etiología , Anciano de 80 o más Años , Autopsia , Resultado Fatal , Femenino , Humanos , Diagnóstico ErróneoRESUMEN
BACKGROUND/AIM: Stage III breast cancer comprises a broad spectrum of disease, including the extent of supraclavicular/internal mammary lymph node metastasis. In this study, we evaluated the usefulness of the absolute lymphocyte count (ALC) and neutrophil-to-lymphocyte ratio (NLR) in predicting the prognosis of patients with stage III breast cancer. PATIENTS AND METHODS: Seventy-five patients with stage III breast cancer who underwent surgery were included. We compared their clinicopathological factors according to the presence or not of supraclavicular/internal mammary lymph node metastasis, and pretreatment ALC or NLR. RESULTS: Patients with metastasis of the studied lymph nodes had a poorer prognosis in comparison to those without metastasis. In patients without these types of lymph node metastasis, both the ALC and NLR were predictive factors for relapse-free and overall survival. Among these patients, those with a low ALC or high NLR had recurrence-free and overall survival comparable to those of patients with supraclavicular/internal mammary lymph node metastasis. CONCLUSION: Pretreatment ALC and NLR were prognostic factors for patients with stage III breast cancer.
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Neoplasias de la Mama/patología , Linfocitos/patología , Neutrófilos/patología , Adulto , Anciano , Anciano de 80 o más Años , Supervivencia sin Enfermedad , Femenino , Humanos , Ganglios Linfáticos/patología , Metástasis Linfática/patología , Recuento de Linfocitos/métodos , Persona de Mediana Edad , Recurrencia Local de Neoplasia/patología , PronósticoRESUMEN
Advanced gastric cancers are responsible for overwhelming human suffering and death. Despite the development of combination chemotherapies, the survival rates of patients with gastric cancer remain unsatisfactory. Given the growing evidence of the benefits of immunotherapy as an alternative treatment for other cancers such as advanced melanoma, non-small cell lung cancer, renal cell carcinoma, and refractory Hodgkin's lymphoma, researchers have begun to explore its application in the treatment of gastric cancer. Three types of immunotherapy have shown promising effects against gastric cancer: immune checkpoint inhibitors, chimeric antigen rector (CAR)-T cells, and tumor vaccines. Clinical trials have used either immuno-oncology monotherapies or combination immuno-chemotherapies to improve the overall survival times and objective response rates of patients with gastric cancer. We review the clinical efficacy of immunotherapy including checkpoint inhibitors, CART, and tumor vaccines, in the treatment of gastric cancer. Based on initial evidence, we believe that immunotherapy could positively impact the natural history and improve the outcomes of a subgroup of patients with gastric cancer.
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Inmunoterapia/métodos , Inmunoterapia/tendencias , Neoplasias Gástricas/terapia , Antígeno B7-H1/inmunología , Antígeno CTLA-4/inmunología , Vacunas contra el Cáncer/uso terapéutico , Terapia Combinada , Humanos , Inhibidores de Puntos de Control Inmunológico/uso terapéutico , Inmunoterapia Adoptiva , Neoplasias Gástricas/mortalidad , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
PURPOSE: In Japan, two courses of CDDP+5-FU (CF) therapy followed by surgery are accepted as a standard treatment for stage II/III esophageal cancer (EC) based on the results of the JCOG9907 trial. To gain a better survival, benefit especially for stage III patients in comparison with CF therapy, a three-arm phase III trial (neoadjuvant setting: CF vs. CF + radiation vs. DOC+CF [DCF]) is ongoing. We have aggressively performed DCF therapy for stage III or IV patients since October 2014. We herein review the outcomes of DCF therapy. METHODS: We retrospectively reviewed the cases of 27 patients with stage III or IV EC (male, n = 24; female, n = 3; median age, 70.0 years) who received DCF therapy. RESULTS: The response rate was 48.1%. Downstaging was achieved over the course of treatment in 14 patients (51.9%). Twenty-six patients transitioned to surgery, with 25 receiving R0 resection. DCF-treated patients who achieved downstaging showed significantly longer relapse-free survival (RFS) than those without downstaging (p = 0.0002). DCF-treated patients with a grade ≥ 1b histological effect showed significantly longer RFS than those with a grade < 1b effect (p = 0.0282). The multivariate analysis showed that downstaging was the only factor significantly associated with RFS in DCF-treated patients. CONCLUSIONS: DCF therapy for stage ≥ III esophageal carcinoma is both feasible and effective. These findings suggest that downstaging and the histological effect might predict the effects of DCF therapy for EC.
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Protocolos de Quimioterapia Combinada Antineoplásica/administración & dosificación , Neoplasias Esofágicas/terapia , Carcinoma de Células Escamosas de Esófago/terapia , Terapia Neoadyuvante/métodos , Recurrencia Local de Neoplasia/epidemiología , Anciano , Cisplatino/administración & dosificación , Supervivencia sin Enfermedad , Docetaxel/administración & dosificación , Esquema de Medicación , Mucosa Esofágica/diagnóstico por imagen , Mucosa Esofágica/efectos de los fármacos , Mucosa Esofágica/patología , Mucosa Esofágica/cirugía , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/mortalidad , Carcinoma de Células Escamosas de Esófago/diagnóstico , Carcinoma de Células Escamosas de Esófago/mortalidad , Carcinoma de Células Escamosas de Esófago/patología , Esofagectomía , Esofagoscopía , Estudios de Factibilidad , Femenino , Fluorouracilo/administración & dosificación , Estudios de Seguimiento , Humanos , Japón/epidemiología , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/prevención & control , Estadificación de Neoplasias , Pirimidinas , Estudios RetrospectivosRESUMEN
An aortoesophageal fistula is often fatal, and standard radical surgery is highly invasive because both bilateral thoracotomy and laparotomy are required. We successfully incorporated thoracoscopic esophagectomy into this procedure for a 43-year-old man with an aortoesophageal fistula. After detaching the esophagus from the adjacent tissue, and leaving just the fistula in the right thoracoscopic procedure, we performed an open aortic graft replacement. Subsequently, we created an omental pedicle graft and wrapped it over the graft. Through this thoracoscopy-thoracostomy approach, minimal destruction of the right thoracic wall was achieved and the successful dissection of the diseased esophagus could be carried out while reducing the amount of bleeding during anticoagulation for cardiopulmonary bypass, and the field of view for the aortic replacement was not disturbed during left thoracotomy. Four months later, we reconstructed the esophagus by a pedunculated small intestinal graft through the ante-thoracic route. A thoracoscopy-thoracotomy approach is therefore considered to be effective and useful for treating a patient with an aortoesophageal fistula.
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Aneurisma de la Aorta Torácica , Enfermedades de la Aorta , Fístula Esofágica , Fístula Vascular , Adulto , Aneurisma de la Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Fístula Esofágica/diagnóstico por imagen , Fístula Esofágica/etiología , Fístula Esofágica/cirugía , Esofagectomía , Humanos , Masculino , Toracoscopía , Toracotomía , Fístula Vascular/diagnóstico por imagen , Fístula Vascular/etiología , Fístula Vascular/cirugíaRESUMEN
X-ray transparent materials are very beneficial for in situ X-ray experiments in the multi-anvil apparatus. We sintered machinable blocks of boron-MgO composites at 800-1000 °C under atmospheric pressure from a mixture of amorphous boron and brucite or Mg(OH)2. The machinability of composite blocks improved with an increase in the brucite content in the starting material; a brucite content higher than 15 wt. % showed reasonable machinability in forming various shapes such as octahedron, cylinder, and sleeve. We confirmed the feasibility of the boron-MgO pressure medium by successfully generating lower mantle pressure (>23 GPa); its pressure generation efficiency is comparable to that of a Cr2O3 doped MgO pressure medium. The boron-MgO composite is expected to be an excellent thermal insulator owing to the extremely low thermal conductivity of amorphous boron; we confirmed its better thermal insulation performance through a comparative heating test with a zirconia sleeve in a Cr2O3 doped MgO pressure medium. Constituting light elements, the boron-MgO composite has high X-ray transparency, which enables us to conduct various cutting edge X-ray measurements in the large volume multi-anvil apparatus.