Polyglycolic acid sheet and fibrin glue for preventing esophageal stricture after endoscopic submucosal dissection: a historical control study.

There have been several reports that steroid administration is effective at preventing strictures after endoscopic submucosal dissection (ESD). However, adverse events after steroid use are of great concern. We have reported that shielding with a polyglycolic acid (PGA) sheet and fibrin glue can be useful for prevention of stricture after ESD. We conducted a retrospective analysis of efficiency of shielding with a PGA sheet and fibrin glue for prevention of esophageal stricture compared with intralesional steroid injection. ESD was performed on a total of 489 lesions in 400 patients for superficial esophageal cancer from January 2012 to July 2016. Of these, 39 lesions were enrolled in the study group (PGA sheet and fibrin glue) and 31 lesions were enrolled in the control group. The incidence of postoperative stricture at 6 weeks and the number of sessions of endoscopic balloon dilatation (EBD) required to resolve any strictures were evaluated. The post-ESD stricture rate was 9.1% in the study group (3/33 patients), which was not significantly lower than the stricture rate of 10.3% in the historical control group (3/29 patients; p = 1.00). The mean number of EBD was 0.057 ± 0.24 in the study group and 1.9 ± 5.1 in the control group, which was not significant (P = 0.95). PGA sheet and fibrin glue appear to be a promising option for the prevention of esophageal stricture similar to the effect of intralesional steroid injection.

Rotatable Offner imaging system for ellipsometric measurement.

To realize high spatial resolution imaging ellipsometric measurement with large field of view, we developed a rotatable Offner system with unit magnification. When the conventional Offner imaging system is tilted relative to the sample plane for the ellipsometric measurement, only a small region of plane is in focus. The rotatable Offner system developed here renders the entire object in focus through all rotations. The performance of the prototype of the Offner system and imaging ellipsometer is tested by generating maps of the ellipsometric parameters Δ and Ψ for samples such as a silicon wafer and a resolution target made of chromium film evaporated on a glass substrate.

Utility of weekly docetaxel combined with preoperative radiotherapy for locally advanced esophageal cancer from pathological analysis.

Esophageal squamous cell cancer (ESCC) is a high-grade carcinoma that is treated with multidisciplinary approaches, including chemoradiotherapy (CRT) followed by surgery. Despite some success with these therapies, overall survival remains poor. In order to investigate a newer CRT regimen, we designed a comparative study to evaluate preoperative CRT using docetaxel (DOC) or 5-Fluorouracil and cisplatin (FU+CDDP [FP] therapy) for treatment of resectable ESCC. In a retrospective review of patients with resectable, locally advanced ESCC, 95 patients received preoperative CRT between 2001 and 2007. CRT was administered using either FP (n = 40) or DOC (n = 55). Pathological response and clinical outcomes were compared between the two groups. Hazard ratios and time-to-event analyses were used to assess outcomes; the ratios were controlled by multivariate logistic regression analysis of potential prognostic factors, and survival was presented with Kaplan-Meier curves. In the FP group, a significant curative effect was observed on the basis of pathological examination of postoperative lesions. However, the DOC group presented a significantly better prognosis on the basis of cumulative survival rates. Logistic regression analysis revealed that the presence of five or more lymph node metastases was an independent predictor of reduced survival. Patients with lymph node metastasis exhibited a better prognosis in the DOC group than those in the FP group. Preoperative CRT for locally advanced esophageal cancer using DOC results in similar or better long-term outcomes compared with FP-based CRT. Therefore, CRT using DOC is a promising therapy option for esophageal cancer.

[Lymph nodes dissection in esophageal cancer surgery].

Esophageal cancer has high incidence and broad distribution of lymph node metastases. Among the sites of possible lymph node metastasis, the station along the recurrent laryngeal nerve shows the highest rate of lymph node metastasis. For complete lymph nodes clearance, dissection of lymph nodes along the nerves of both sides is essential. The procedure of lymph node dissection along the recurrent laryngeal nerve is a good indicator of the whole quality of the surgery. In order to reduce the morbidity of lymph node dissection, we preserve bronchial artery and pulmonary branches of the vagal nerve. The postoperative complication rate of esophageal cancer surgery is higher comparing other gastrointestinal cancer operations. Pulmonary complication occurs in high rate, and sometimes leads to mortality. On the 2nd and 3rd postoperative day, we have to be very careful for cardiopulmonary condition of the patient. The accuracy and quality of lymph node dissection is closely related to both curability and morbidity.

Correlation between loss of Bcl-XL expression and improved prognosis in advanced esophageal cancer treated by preoperative chemoradiotherapy.

We investigated the clinical significance of the apoptosis- related molecule expression of tumor cells in patients with advanced esophageal cancer treated with preoperative chemoradiotherapy (CRT). Preoperative CRT reduced Bcl-X(L) expression in a significant proportion of the group responding to CRT but not in the group resisting CRT, although Bcl-2 expression was reduced in both groups. The mean survival time of the patients with cancers that lost Bcl-X(L) following CRT was significantly longer compared to those with cancers expressing Bcl-X(L). These results suggested that CRT reduced Bcl-X(L) expression, and this decrease closely correlated with the prolonged survival of advanced esophageal cancer patients treated with preoperative CRT.

Circulating micrometastases of esophageal cancer detected by carcinoembryonic antigen mRNA reverse transcriptase-polymerase chain reaction: clinical implications.

In some patients without distant metastases according to conventional preoperative investigations, relapse occurs in distant organs within a few years after radical resection of esophageal cancer. Various attempts have been made to detect micrometastases that are not found by conventional techniques. A quantitative real-time reverse-transcriptase polymerase chain reaction was used to detect messenger RNA for carcinoembryonic antigen in 147 blood samples from 49 patients scheduled for radical resection of esophageal cancer at Juntendo University Hospital between September 2003 and June 2004. The number of circulating cancer cells was assessed and the clinical significance of detecting such micrometastases was analyzed. Multivariate analysis showed that positivity of this assay was significantly associated with pT1 or pT2 disease and stage III or stage IV disease. Patients with more than 40-50 carcinoembryonic antigen mRNA copies among 10(4) normal cells on quantitative analysis had a higher recurrence rate. The number of tumor cells circulating in the blood may have more influence on the prognosis of esophageal cancer than the presence of tumor cells.

[Comparison of right ventricular function between prevention and enlargement of pulmonary valve annulus after repair of tetralogy of Fallot; mid-term results].

Total of 41 patients with tetralogy of Fallot (TOF) who underwent intracardiac repair from 1993 to 1998 were divided into 2 groups: preservation (n = 14) or enlargement (n = 27) of the pulmonary valve annulus. The procedure was decided on the Z value of the annular size: above or under -2 SD of the standard value. Although postoperative right ventricular (RV) diastolic volume (RVEDV) and cardiothoracic ratio (CTR) were larger than the preservation group and pulmonary regurgitation (PR) existed in the enlargement group, RV pressure was decreased and central venous pressure (CVP) was low and RV contraction was preserved. The exercise capacity was also good and no significant arrhythmia was recognized. Our mid-term results showed that appropriate enlargement of the pulmonary valve annulus preserved good RV function in patients with TOF.

[Surgery for cancer of the esophagus in elderly patients].

Esophageal cancer has a fulminant biological characteristic, and shows a higher rate of lymph node metastasis than other gastrointestinal malignancies. The distribution of lymphatic spread is wide from cervical to abdominal field, and 3-field lymph node dissection is a standard procedure in esophageal cancer surgery. However, the morbidity and mortality rate following esophageal resection is higher than that of other gastrointestinal or thoracic surgery. The most serious postoperative complication of esophageal surgery in elderly patients is a pulmonary problem. In order to reduce postoperative pulmonary complications, we try to preserve bronchial artery, pulmonary branches of the vagal nerve, in addition to definite preservation of bilateral recurrent laryngeal nerve. Our survival rate and mean survival period in elderly patients with esophageal cancer was fairly good. To achieve a high survival rate and reduce postoperative morbidity and mortality in elderly patients, preoperative assessment of pulmonary function and quality control of surgical procedure is essential.

[Differences in postoperative course by preoperative left ventricular volume after closure of ventricular septal defect during early infancy].

A total of 38 early infants with ventricular septal defect (VSD) were divided into 2 groups by preoperative LVEDV. The group A (n=14, LVEDV>250% N) showed significantly longer period of intubation, cathecholamine drip, and hospitalization compared with the group B (n=28, LVEDV<250% N). At dischage, both groups showed significant lowered right ventricular (RV) pressure, but LVSF in the group A was significantly lower than that in the group B. The patients with larger left ventricular (LV) volume preoperatively were thought to be potential high-risk groups in cardiac and pulmonary function and their postoperative course was prolonged and recovery of LV function was worse. In such patients, special care is mandatory to do postoperative management and to decide timing of operation.

Clinical significance of bone marrow micrometastases in esophageal cancer.

Using the reverse transcriptase-polymerase chain reaction (RT-PCR), we investigated the clinical significance of bone marrow micrometastases in patients with esophageal cancer. Bone marrow samples from 57 patients with esophageal cancer, who underwent esophagotomy, were investigated by specific RT-PCR for carcinoembryonic antigens (CEA). A total of 40 out of 57 patients (70.1%) were positive for CEA mRNA in the bone marrow. Among curatively resected cases, 34 of 50 patients (68.0%) were positive for CEA. Ten of 13 T1 patients (76.9%) were positive for CEA. Although the CEA-positive rate was high, there was no significant correlation between CEA positivity and any clinical characteristics. Among the 40 CEA-positive patients, 50% have shown recurrence so far. Detection of cancer cells in the bone marrow by RT-PCR may not always correspond to the malignant potential or other characteristics of the tumor. CEA-positive 'micrometastases' might actually represent isolated circulating tumor cells without much biological significance.

Flavopiridol as a radio-sensitizer for esophageal cancer cell lines.

Flavopiridol is a synthetic flavone that has shown an antitumor effect against several cancers. Here, we investigated the in vitro effect of flavopiridol alone and the combined effect of low-dose flavopiridol plus radiation on esophageal squamous cell carcinoma cell lines. Esophageal squamous cell carcinoma cell lines (TE8, TE9 and KE4) were exposed to flavopiridol (0.05-400 nmol/L) for 48 h. Growth inhibition was evaluated by MTT assay, cell cycle distribution was determined by flow cytometry, and cyclin D1, Bcl-2 and Rb protein expression was detected by Western blotting. The effect of 0.05 nmol/L flavopiridol as a radio-sensitizer was determined by clonogenic assay. The IC50 was approximately 110-250 nmol/L. Exposure to 0.05 nmol/L flavopiridol for 48 h increased the G2/M population, while 300 nmol/L increased the G1 population. At a concentration of 300 nmol/L, nuclear fragmentation and chromatin condensation were observed in all three cell lines. Exposure to 300 nmol/L flavopiridol decreased the levels of cyclin D1 and Rb protein in all three cell lines and Bcl-2 protein was also decreased in TE8 and KE4 cells. Moreover, exposure to 0.05 nmol/L flavopiridol slightly decreased the levels of cyclin D1, Rb and Bcl-2 protein in KE4 cells. Flavopiridol treatment (0.05 nmol/L) enhanced the radio-sensitivity in all three cell lines. Low-dose flavopiridol augmented the response of esophageal squamous cell carcinoma cell lines to radiation. Administration of a low dose of flavopiridol could be a potent new therapeutic approach for improving the efficacy of radiotherapy against esophageal cancer.

[Congenital supravalvular aortic stenosis; report of a case].

We experienced a successful surgical case of extended aortoplasty by means of Doty's method (two sinus reconstruction) for congenital supravalvular aortic stenosis (SAS). Case was 12-year-old boy, who had no complaint except heart murmur. The retrograde aortography demonstrated localized stenosis just above the aortic valve, and it was an hour-glass type. The preoperative peak systolic pressure gradient between the left ventricle and ascending aorta was 56 mmHg, which was improved postoperatively. This case showed excellent results. Doty's aortoplasty was favorable method for SAS without deformity of aortic valve and coronary obstruction.

Mutation of the p53 gene predicts lymph node metastases in Japanese patients with esophageal carcinoma: DNA and immunohistochemical analyses.

We evaluated the clinicopathologic significance of p53 gene mutations, including a comparison of DNA analysis and immunohistochemical examination, in Japanese patients with esophageal squamous cell carcinoma, a highly aggressive cancer. Genomic DNA isolated from 76 tumors without preoperative treatment was subjected to polymerase chain reaction and sequencing. Associations were sought between p53 mutations and clinicopathologic characteristics. Cases also were investigated immunohistochemically to detect abnormal p53 protein accumulation. Overexpression of p53 protein occurred in 51 cases (67.1%), while gene mutations in the examined exons were found in only 14 (18.4%). By multivariate analysis, p53 mutation predicted detection of eight or more lymph node metastases. Mutations of the p53 gene may not only participate in the initiation of esophageal cancer, but also may promote lymph node metastasis. Unlike gene mutations, p53 protein overexpression did not predict nodal metastasis extent.

Successfully treated case of cervical abscess and mediastinitis due to esophageal perforation after gastrointestinal endoscopy.

Perforations of the esophagus are uncommon complications of flexible gastrointestinal endoscopy. Perforations after endoscopy are likely to occur in the cervical esophagus, where fiber insertion is difficult anatomically. The diagnosis should be made as soon as possible, because mediastinitis and sepsis frequently develop following esophageal perforations. The surgical strategies are dependent on the location of the perforations and the condition of the patients. For a successful outcome, surgery is a preferred treatment for most perforation cases, and non-operative treatment, such as antibiotics, parental nutrition, and no food intake by mouth, should be applied carefully.

Histopathologic effects of neoadjuvant therapies for advanced squamous cell carcinoma of the esophagus: multivariate analysis of predictive factors and p53 overexpression.

In 97 patients (60, chemotherapy; 22, chemoradiotherapy; 15, radiotherapy), histopathologic effects were evaluated microscopically, and histologic response rates were compared among three neoadjuvant treatment modalities. Predictive factors for neoadjuvant therapies were analyzed by logistic regression, including the results of p53 immunohistochemical staining. In the chemoradiotherapy group, the pathologic response rate was 86.4%, and was significantly higher than that for chemotherapy (P < 0.0001) or for radiotherapy (P = 0.0031). In patients with normal p53 protein expression, the histopathologic response rate to chemotherapy was 20.0%, a higher rate than that for patients with abnormal p53 overexpression. In the chemoradiotherapy or radiotherapy group, however, the response rates were almost the same, irrespective of p53 oncoprotein status. From multivariate analysis, the neoadjuvant treatment modality itself was identified as the most powerful predictive factor for the effect. Chemoradiotherapy had the most powerful effect on advanced esophageal cancer, and p53 status did not influence the clinical outcome in this group.

[Factors allowing continuous working of female nurses in the People's Republic of China--survey of 15 hospitals in 5 areas].

PURPOSE: Few investigations have been conducted on working, childcare and home education among female nurses (nurses) in the People's Republic of China (P.R. of China). The purpose of this study was to clarify the factors allowing continued working of female nurses. METHODS: The subjects were nurses from 15 hospitals in 3 provinces and 2 autonomous areas. They were surveyed by questionnaire regarding their childcare and home education. In was distributed by the Ministry of Health in the P.R. of China and the data were collected between February and April in 1996. RESULTS: A total of 4,284 (80.0%) questionnaires were collected. 1. About 60% of the nurses began working when they were 15 to 19 years old. The average length of service was 13.9 years. 2. Their professional position correlated directly with their years of service. 3. 4.3% of them had not continued working. 4. The nurses entrust their children to day-care institutions (61.2%) or grandparents (22.3%) during the daytime, and to the father (66.3%) or the grandparents (19.5%) during the night. 5. 17.6% of them have experienced being away from home for more than one month due to their job. 6. 66.8% of the nurses have experienced more than one month official trip, and had children under 14 years old at the time. They entrusted their children to day-care institutions (34.1%), to the father (29.2%) and grandparents (25.3%) during the official trip. CONCLUSIONS: In summary, most nurses are employed when they are young and go on working as nurses. It is possible for them to continue their work after marriage, childbirth, and while they are bringing up their children. The high rate of working woman, sufficient nursery schools and family cooperation in housework can be pointed out as main factors that enable them to continue their work.

[Childcare and home education in families of female nurses in the People's Republic of China--survey of 15 hospitals in 5 areas].

PURPOSE: The purpose of this study was to investigate the actual conditions of childcare and home education among families of female nurses in the P. R. of China. METHODS: The subjects were nurses from 15 hospitals in 3 provinces and 2 autonomous areas. They were surveyed by questionnaire regarding their childcare and home education. It was distributed by the Ministry of Health in the P. R. of China and data were collected between February and April in 1996. RESULTS: A total of 4284 (80.0%) questionnaires were collected. 1. The age of the subjects was between 18 and 62 years old with a mean of 32.9 +/- 9.0 (SD) years 71.4% of them had husbands, whose ages were between 23 and 71 years old, the mean age being 38.3 +/- 8.4 (SD) years. The family types were 63.2% nuclear family and 33.7% extended family, with 3.1% being single. 65.1% of the subjects had children, whose mean number was 1.1 +/- 0.4 (SD). Firstborn children were 49.9% girls and 50.1% boys. 2. The most popular method of infant nutrition was breast-feeding, utilized by 60.1%. The highest rate (67.8%) was in the age group of 25 to 29 years old (P < 0.01). 3. The practice of "swaddling" (wrapping the child so as not to allow movement) was more common in the over 40 year old age group than the under 40 year old group (P < 0.01). Swaddling-practice showed significant differences by area. 4. The rates for children who helped with housework were 50.3% for girls and 46.7% for boys. 5. A number of children between 7 and 18 years old were studying English privately. 6. The greatest expectation of the subjects, for their children aged between 7 and 18 years old, was to study. CONCLUSIONS: 1. Infant nutrition showed significant differences between generations, and swaddling-practice differed with the generation and the area. 2. Although girls help their parents more than boys in Japan, boys and girls equally helped their parents in the P. R. of China. 3. Concerning the topics of private learning and parents expectations, the results were similar to those in Japan.

[A case of convergence spasm in hysteria improved with a brief psychiatric assessment].

We report a 16-year-old female who developed double vision. The diplopia was in the horizontal plane and persisted for 3 weeks. She also complained of headache and nausea. She kept her eyes closed unless she was told to open. When eyelids were passively open, both eyes deviated inward in an adducted position. The pupil size and the reaction to light were normal. No weakness was noted in the extraocular muscles when each eye was examined individually. The rest of the neurologic examinations were normal. We thought that she had a convergence spasm. Brain CT and MRI were normal. The CSF and blood chemistries were also normal. We treated her with supportive psychotherapy and her convergence spasm disappeared. We concluded that her convergence spasm was a manifestation of conversion hysteria.

Outcomes of extended lymph node dissection for squamous cell carcinoma of the thoracic esophagus.

Patients with thoracic esophageal carcinoma who underwent extended lymph node (LN) dissection were studied to assess the state of LN metastasis and evaluate its outcome in terms of a prognostic benefit. Pertaining to LN metastasis, it was found that depending on the location of a primary tumor, the area of choice, in which metastasis tends to develop predominantly, showed some variation. However, irrespective of the location of the tumor, the predominant growth of positive nodes was found to locate among three fields, namely the neck, mediastinum and abdomen even in patients with a single metastatic node. This suggests that extended LN dissection including the neck, mediastinum and abdomen should be considered mandatory, if a complete removal of the tumors for carcinoma of the thoracic esophagus is to be desired. Multivariate analysis revealed importance of LN dissection as a prognostic factor. A cumulative survival rate in the patients with lymphadenectomy through right thoracotomy was statistically better than that in the patients who underwent blunt extraction of the esophagus without lymphadenectomy. Furthermore, extensiveness of LN dissection could effectively serve as a prognostic factor. Consequently, three-field LN dissection yields a prognostic benefit to improve a long term survival in patients with carcinoma of the thoracic esophagus.

[Outpatient treatment for gastrointestinal tract cancer in the Department of Surgery].

Recently, outpatient cancer treatment has been rapidly increasing in order to cut medical expenditures and promote the QOL of cancer patients. However, the efficacy of outpatient cancer treatment is still uncertain. When performing outpatient cancer treatment, one must have a clear idea of the expected effect, and provide appropriate treatment so that none of the expected benefit is sacrificed for the improved convenience.