Intragastric free cancer cells may be attached to automatic staplers during anastomosis in patients with gastric cancer.

BACKGROUND: Automatic staplers are often used to reconstruct the digestive tract during surgeries for gastric cancer. Intragastric free cancer cells adhering to automatic staplers may come in contact with the laparoscopic port area and progress to port site recurrence. This study aimed to investigate the presence/absence of cancer cells adhering to automatic staplers during gastric cancer surgery using cytological examinations. We further determined the positive predictive clinicopathological factors and clinical implications of free cancer cells attached to automatic staplers. METHODS: This study included 101 patients who underwent distal gastrectomy for gastric cancer. Automatic staplers used for anastomosis in gastric cancer surgeries were shaken in 150 ml of saline solution to collect the attached cells. Papanicolaou stains were performed. We tested the correlation between cancer-cell positivity and clinicopathological factors to identify risk factors arising from the presence of attached cancer cells to the staplers. RESULTS: Based on the cytology, cancer cells were detected in 7 of 101 (6.9%) stapler washing fluid samples. Univariate analysis revealed that circular staplers, type 1 tumors, and positive lymph nodes were significantly associated with higher detection of free cancer cells adhering to staplers. No significant differences in other factors were detected. Of the seven cases with positive cytology, one developed anastomotic recurrence. CONCLUSIONS: Exfoliated cancer cells adhered to the automatic staplers used for anastomoses in 6.9% of the staplers used for distal gastrectomies in patients with gastric cancer. Staplers used for gastric cancer surgeries should be handled carefully.

Early-stage gastric cancer with solitary brain metastasis four years after curative surgery: a case report and literature review.

Brain metastasis post-curative gastrectomy for early-stage gastric cancer is extremely rare. We present herein, a case of solitary brain metastasis that developed 4 years post-curative surgery for early-stage gastric cancer. A 60-year-old man had early-stage gastric cancer 4 years prior to presentation and underwent laparoscopy-assisted distal gastrectomy with lymph node dissection. The pathological TNM classification was T1b (submucosal) N0M0. He underwent scheduled examinations and had no recurrence. 4 years postoperatively, he presented to the emergency department with sudden onset of nausea, vomiting, and inability to speak clearly. Brain computed tomography revealed a 17-mm nodule in the right cerebral hemisphere and midline shift. The tumor could not be radically resected for anatomical reasons, and incisional biopsy was performed for histological examination. Histological examination confirmed the diagnosis of a poorly differentiated adenocarcinoma from the previous gastric cancer. Gamma knife radiosurgery and chemotherapy were scheduled. 28 months after brain metastasis, multiple liver and lung metastases appeared. The patient died 30 months after developing brain metastasis. Brain metastasis may occur during long-term follow-up even after curative resection of early-stage gastric cancer. In patients with a history of gastric cancer and neurological symptoms, brain metastasis should be considered.

STK11 p.F354L Germline Mutation in a Case of Multiple Gastrointestinal Tumors.

Serine/threonine kinase 11 (STK11) is known as a critical tumor-suppressor gene that is frequently mutated in a broad spectrum of human cancers. Among these, the p.F354L mutation of STK11 has been identified in sporadic colon or lung cancer cases. Here, we report the case of a 75-year-old male patient who underwent surgical treatment for multiple tumors of the gastrointestinal system. Genetic mutations were screened in all resected samples, including duodenal high-grade adenoma, gastric high-grade adenoma, rectal adenocarcinoma, and liver metastasis of rectal adenocarcinoma, by next-generation sequencing for mutational hotspots involving 50 oncogenes and tumor suppressor genes. The characteristic hamartomatous polyp of Peutz-Jeghers syndrome was not detected in any tumor specimen. However, all samples as well as the normal rectal mucosa harbored the genetic mutation p.F354L in STK11. In addition, somatic mutations coexisted in the tumor samples, including KRAS p.A146T, TP53 p.G238X, and APC p.T1556fs in the duodenal adenoma; TP53 p.G238Y and APC p.T1556fs in the gastric adenoma; and TP53 p.R282W in the rectal adenocarcinoma and metastatic liver cancer. No somatic mutation was detected in the normal rectal mucosa as a control sample. To our knowledge, this is the first report of an STK11 germline mutation in a patient with multiple tumors of the gastrointestinal tract.

First Principles Calculations Toward Understanding SERS of 2,2'-Bipyridyl Adsorbed on Au, Ag, and Au-Ag Nanoalloy.

First principles electrodyanmics and quantum chemical simulations are performed to gain insights into the underlying mechanisms of the surface enhanced Raman spectra of 22BPY adsorbed on pure Au and Ag as well as on Au-Ag alloy nanodiscs. Experimental SERS spectra from Au and Ag nanodiscs show similar peaks, whereas those from Au-Ag alloy reveal new spectral features. The physical enhancement factors due to surface nano-texture were considered by numerical FDTD simulations of light intensity distribution for the nano-textured Au, Ag, and Au-Ag alloy and compared with experimental results. For the chemical insights of the enhancement, the DFT calculations with the dispersion interaction were performed using Au20 , Ag20 , and Au10 Ag10 clusters of a pyramidal structure for SERS modeling. Binding of 22BPY to the clusters was simulated by considering possible arrangements of vertex and planar physical as well as chemical adsorption models. The DFT results indicate that 22BPY prefers a coplanar adsorption on a (111) face with trans-conformation having close energy difference to cis-conformation. Binding to pure Au cluster is stronger than to pure Ag or Au-Ag alloy clusters and adsorption onto the alloy surface can deform the surface. The computed Raman spectra are compared with experimental data and assignments for pure Au and Ag models are well matching, indicating the need of dispersion interaction to reproduce strong Raman signal at around 800 cm-1 . This work provides insight into 3D character of SERS on nanorough surfaces due to different binding energies and bond length of nanoalloys. © 2018 Wiley Periodicals, Inc.

Gastric washing by distilled water can reduce free gastric cancer cells exfoliated into the stomach lumen.

PURPOSE: Intragastric free cancer cells in patients with gastric cancer have rarely been studied. The purpose of this study was to investigate the detection rate of intragastric free cancer cells in gastric washes using two types of solutions during endoscopic examination. We further clarified risk factors affecting the presence of exfoliated free cancer cells. METHODS: A total of 175 patients with gastric cancer were enrolled. Lactated Ringer's solution (N = 89) or distilled water (DW; N = 86) via endoscopic working channel was sprayed onto the tumor surface, and the resultant fluid was collected for cytological examination. We compared the cancer-cell positivity rate between the two (Ringer and DW) groups. We also tested the correlation between cancer-cell positivity and clinicopathological factors in the Ringer group to identify risk factors for the presence of exfoliated cancer cells. RESULTS: The cancer-cell positivity rate was significantly higher in the Ringer group than that in the DW group (58 vs 6%). Cytomorphology in the Ringer group was well maintained, but not in the DW group. The larger tumor size (≥ 20 mm) and positive lymphatic involvement were significant risk factors of exfoliated free cancer cells. CONCLUSIONS: Cancer cells can be highly exfoliated from the tumor surface into the gastric lumen by endoscopic irrigation in large gastric cancer with lymphatic involvement. Gastric washing by DW can lead to cytoclasis of free cancer cells; therefore, it may minimize the possibility of cancer-cell seeding in procedures carrying potential risks of tumor-cell seeding upon transluminal communication, such as endoscopic full-thickness resection and laparoscopy-endoscopy cooperative surgery.

Comparison between endoscopic and laparoscopic removal of gastric submucosal tumor.

BACKGROUND AND AIM: A retrospective study was conducted to compare two resection methods, namely, endoscopic resection (ER) procedures (endoscopic submucosal dissection [ESD], endoscopic muscularis dissection [EMD], and endoscopic full-thickness resection [EFTR]) and laparoscopic resections (LR) (laparoscopic endoscopic cooperative surgery [LECS] and laparoscopic wedge resection). METHODS: Seventy-three patients who underwent ER (N = 33: ESD, N = 4; EMD, N = 15; EFTR, N = 14) or LR (N = 39: LECS, N = 16; wedge resection, N = 23) for gastric submucosal tumor (G-SMT) smaller than 50 mm were included in this study. Patient/tumor characteristics and intra/postoperative factors were compared between the ER and LR groups. RESULTS: The ER group had a significantly higher percentage of intraluminal growing type of tumor (100% vs 41%) and smaller tumor size (23 vs 33 mm) than the LR group. The ER group had a significantly shorter operative time (93 vs 145 min) and less blood loss (13 vs 30 mL) than the LR group. In the ER group, three patients who had tumors located on the anterior wall of the stomach required laparoscopic closure after EFTR because of difficulty in endoscopic closure of the gastric-wall defect. Postoperative complication rates and duration of postoperative hospital stays did not differ between the two groups. CONCLUSIONS: ER may be technically feasible, safe, less invasive, and oncologically appropriate options for selected patients with the intraluminal growing type of G-SMT smaller than 30 mm. EFTR may be more reasonable alternatives to LR in selected patients with a small G-SMT located on the lesser curvature side.

Establishment of pathological quantitative method for determining undifferentiated component ratio in patients with differentiated/undifferentiated mixed-type early gastric cancer and clinical significance of this ratio.

PURPOSES: The purpose of this study was to establish a pathological quantitative method for determining the undifferentiated components ratio (UCR) in patients with differentiated/undifferentiated mixed-type (Mixed-type) early gastric cancer (EGC) and to examine the clinical significance. METHODS: The subjects were 410 patients who underwent surgical resection for EGC with the invasion limited to m or sm1. Analysis 1: In 12 randomly selected patients with Mixed-type cancer, we calculated the area ratio and the ratio of the length ratio using ImageJ and analyzed the correlation between them. Analysis 2: We generated ROC curves, and determined the cutoff UCR on the basis of the predictive risk factors for lymph node metastasis (LNM). Analysis 3: We analyzed the relationship between clinicopathological factors including UCR/length of undifferentiated component (LUC = maximum dimensions of tumor × UCR) and LNM. RESULTS: Analysis 1: The length ratio can be used as a substitute parameter for the UCR (r = 0.996). Analysis 2: The cutoff UCR as a risk factor for LNM was 58% (sensitivity = 1, 1 - specificity = 0.404). Analysis 3: Lymphovascular invasion (p < 0.0001), UCR ≥58% (p = 0.023), and LUC ≥25 mm (p = 0.005) were identified as significant risk factors for LNM. No LNM was observed in patients with invasion limited to m or sm1 and negativity for lymphovascular invasion and UCR <58% (0/215). CONCLUSIONS: In the patients with Mixed-type EGC, the length ratio of undifferentiated components can be a substitute parameter for the UCR. LNM rarely occurs in patients without lymphovascular invasion and with an UCR <58%. The analysis of the UCR has great significance in determining whether additional surgical resection is required after endoscopic resection.

Endoscopic self-expandable metal stent placement for malignant afferent loop obstruction caused by peritoneal recurrence after total gastrectomy.

Afferent loop obstruction (ALO) caused by cancer recurrence after total gastrectomy (TG) can be managed by either surgical or non-surgical treatment. The general condition of patients with recurrent gastric cancer is often poor, so a less invasive non-surgical treatment is desirable. We report the case of a 75-year-old male who had undergone TG for gastric cancer 6 months previously and who presented at our hospital with abdominal pain and vomiting. Abdominal computed tomography scan showed a dilated afferent loop, and additionally a low-density lesion around jejunojejunal anastomosis, suggesting that ALO is associated with peritoneal recurrence. A self-expandable metal stent (SEMS) was endoscopically placed to treat ALO after decompression of the dilated afferent loop using an intestinal tube. He retained a good quality of life until his death due to cancer progression 5 months after the SEMS placement. Our case indicates that SEMS could be a less invasive alternative to surgery, and may confer a better quality of life for patients with ALO due to cancer recurrence after TG. This is the valuable report of case in which endoscopic metallic stent placement succeeded for ALO caused by peritoneal recurrence after TG.

Optical readout of hydrogen storage in films of Au and Pd.

For hydrogen sensor and storage applications, films of Au and Pd were (i) co-sputtered at different rates or (ii) deposited in a sequentially alternating fashion to create a layered structure on a cover glass. Peculiarities of hydrogen uptake and release were optically monitored using 1.3 µm wavelength light. Increase of optical transmission was observed for hydrogenated Pd-rich films of 10-30 nm thickness. Up to a three times slower hydrogen release took place as compared with the hydrogen uptake. Compositional ratio of Au:Pd and thermal treatment of films provided control over the optical extinction changes and hydrogen uptake/release time constants. Higher uptake and release rates were observed in the annealed Au:Pd films as compared to those deposited at room temperature and were faster for the Auricher films. Three main parameters relevant for sensors: sensitivity, selectivity, stability (reproducibility) are discussed together with the hydrogenation mechanism in Au:Pd alloys.

Laparoscopy-assisted full-thickness resection of the duodenum for patients with gastrointestinal stromal tumor with ulceration.

INTRODUCTION: Gastrointestinal stromal tumor (GIST) with ulceration may potentially disseminate into the peritoneal cavity after laparoscopic local wedge resection (full-thickness resection) when the intestinal wall is opened under the aeroperitoneum. To prevent this intraoperative tumor seeding, we developed laparoscopy-assisted full-thickness resection (LAFTR) of the duodenum for GIST with ulceration. Here, we present the preliminary results of LAFTR. METHODS: Three patients with duodenal GIST with ulceration underwent LAFTR. LAFTR consists of four major procedures: (i) a laparoscopic Kocher maneuver (mobilization of the pancreatoduodenum); (ii) the creation of a small upper median laparotomy; (iii) the extracorporeal completion of the full-thickness resection under direct vision; and (iv) extracorporeal hand-sewn closure of the duodenal defect. RESULTS: LAFTR was successfully performed without any intraoperative adverse events. The mean operating time and estimated blood loss were 182 min and 34 mL, respectively. Postoperative contrast roentgenography showed neither duodenal deformity nor disturbance of gastroduodenal emptying in any of the patients. None of the patients developed peritoneal recurrence. CONCLUSIONS: LAFTR can eliminate the possibility of peritoneal or port-site seeding of tumor cells because the duodenotomy and tumor excision are performed extracoporeally. Meticulously hand-sewn closures of the duodenal defect can minimize the possibilities of anastomotic insufficiency and deformity. LAFTR is a feasible, safe, and minimally invasive treatment for patients with GIST with ulceration in the first and second portions of the duodenum.

Au-Ag-Cu nano-alloys: tailoring of permittivity.

Precious metal alloys enables new possibilities to tailor materials for specific optical functions. Here we present a systematic study of the effects of a nanoscale alloying on the permittivity of Au-Ag-Cu metals at 38 different atomic mixing ratios. The permittivity was measured and analyzed numerically by applying the Drude model. X-ray diffraction (XRD) revealed the face centered cubic lattice of the alloys. Both, optical spectra and XRD results point towards an equivalent composition-dependent electron scattering behavior. Correlation between the fundamental structural parameters of alloys and the resulting optical properties is elucidated. Plasmonic properties of the Au-Ag-Cu alloy nanoparticles were investigated by numerical simulations. Guidelines for designing plasmonic response of nano- structures and their patterns are presented from the material science perspective.

Successful treatment of large adenoma extending close to the papilla in the duodenum by laparoscopy-assisted pancreas-sparing duodenectomy.

A 54-year-old man had a 65-mm infrapapillary, circular, and laterally spreading tubular adenoma in the distal second and proximal third parts of the duodenum. The papilla was 15 mm from the proximal margin of the tumor. Because the patient requested organ-preserving laparoscopic surgery, we conducted laparoscopy-assisted pancreas-sparing duodenectomy (LAPSD). LAPSD consists of five major procedures: (i) laparoscopic wide Kocher maneuver and transection of the proximal jejunum; (ii) laparoscopic separation of the duodenum from the pancreas; (iii) creation of a small upper median laparotomy; (iv) extracorporeal completion of the segmental duodenectomy; and (v) extracorporeal intestinal reconstruction. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. Histopathological examination revealed that the circumferential margin of the specimen was negative for tumor cells. LAPSD provided a clear margin without damaging the papilla and eliminated the possibility of peritoneal or port-site seeding of tumor cells because part of the procedure was performed extracorporeally. LAPSD is a useful alternative to pancreatoduodenectomy in patients with a large adenoma extending close to the papilla in the duodenum.

Laparoscopic Repair of Internal Transmesocolic Hernia of Transverse Colon.

Introduction. Internal hernias are often misdiagnosed because of their rarity, with subsequent significant morbidity. Case Presentation. A 61-year-old Japanese man with no history of surgery was referred for intermittent abdominal pain. CT suggested the presence of a transmesocolic internal hernia. The patient underwent a surgical procedure and was diagnosed with transmesocolic internal hernia. We found internal herniation of the small intestine loop through a defect in the transverse mesocolon, without any strangulation of the small intestine. We were able to complete the operation laparoscopically. The patient's postoperative course was uneventful and the patient was discharged on postoperative day 6. Discussion. Transmesocolic hernia of the transverse colon is very rare. Transmesocolic hernia of the sigmoid colon accounts for 60% of all other mesocolic hernias. Paraduodenal hernias are difficult to distinguish from internal mesocolic transverse hernias. We can rule out paraduodenal hernias with CT. Conclusion. The patient underwent a surgical procedure and was diagnosed with transmesocolic internal hernia. We report a case of a transmesocolic hernia of the transverse colon with intestinal obstruction that was diagnosed preoperatively and for which laparoscopic surgery was performed.

Preoperative vs Postoperative Eradication of Helicobacter pylori in 150 Patients with Gastric Cancer: A Randomized Controlled Trial.

BACKGROUND: The Maastricht, Asia-Pacific consensus guidelines strongly recommend eradication of Helicobacter pylori in patients who have a history of gastric cancer. This open-label, single-center, randomized controlled trial was conducted to investigate the appropriate timing of eradication for patients undergoing gastrectomy. STUDY DESIGN: One hundred and fifty patients scheduled to undergo gastrectomy were allocated to either a preoperative or a postoperative group. The eradication regimen was a common triple therapy: rabeprazole, amoxicillin, and clarithromycin [corrected]. Patients in the preoperative group were treated with the regimen, followed by surgery, and patients in the postoperative group were treated after postoperative day 8. The primary end point was the proportion of patients achieving successful eradication in the remnant stomach. The definition of successful eradication was negativity in both the C13 urea breath test and for the antigen in feces at 6 months after surgery. RESULTS: Eight patients were excluded, and the remaining one hundred and forty-two, 70 in the preoperative group and 72 in the postoperative group, were included on an intention to treat basis. The procedures used were gastrectomy with Billroth I, Roux-en-Y, and pylorus-preserving gastrectomy in 18, 70, and 57 patients, respectively. The proportion of patients showing successful eradication hardly differed between the 2 groups, 68.6% vs 69.4% (p = 1.000) in the pre- and postoperative groups, respectively. Subgroup analysis also demonstrated no significant difference among the reconstruction methods used. CONCLUSIONS: Preoperative H pylori eradication therapy for gastric cancer patients scheduled for gastrectomy is not necessary, regardless of the planned reconstruction procedure.

Laparoscopy-assisted transduodenal excision of superficial non-ampullary duodenal epithelial tumors.

INTRODUCTION: Transduodenal excision (transduodenal submucosal dissection) is an alternative to pancreaticoduodenectomy for the treatment of benign and low-grade malignant tumors of the duodenum. However, laparoscopic transduodenal excision or laparoscopy-assisted transduodenal excision (LATDE) of such tumors has been rarely reported. In this paper, we present the preliminary results of LATDE in patients with superficial non-ampullary duodenal epithelial tumors. METHODS: Three patients with superficial non-ampullary duodenal epithelial tumors (mucosal adenocarcinoma, n = 1; tubular adenoma, n = 2) underwent LATDE. LATDE consists of four major procedures: (i) laparoscopic wide Kocher maneuver (mobilization of the pancreaticoduodenum); (ii) extracorporeal approach to the fully mobilized duodenum through the upper median longitudinal incision (4 cm in length); (iii) tumor excision by submucosal dissection under direct vision through longitudinal duodenotomy (4 cm in length); and (iv) hand-sewn closure of the mucosal defect and duodenotomy. RESULTS: LATDE was successfully carried out without any intraoperative or postoperative adverse events. The mean operating time and estimated blood loss were 155 min and 17 mL, respectively. Contrast roentgenography on postoperative day 4 showed neither duodenal deformity nor disturbance of gastroduodenal emptying in any of the patients. CONCLUSIONS: LATDE could eliminate the possibility of peritoneal or port-site seeding of tumor cells because the duodenotomy and tumor excision are performed extracorporeally. The meticulously hand-sewn closures of the mucosal defect and duodenotomy can minimize the possibility of postoperative hemorrhage and/or anastomotic leakage. LATDE is a feasible, safe, and minimally invasive treatment for patients with superficial non-ampullary duodenal epithelial tumors that have no risk of lymph node metastasis in the first and second portions of the duodenum.

Identification of factors involved in recovery of heat-injured Salmonella Enteritidis.

Proteins and genes involved in the recovery of heat-injured Salmonella Enteritidis were investigated. Salmonella Enteritidis cells cultured overnight in tryptic soy broth (TSB; nonselective medium) were suspended in citric acid-disodium hydrogen phosphate buffer (pH 6). After heat treatment at 55 degrees C for 15 min, the culturable counts measured by tryptic soy agar (TSA; nonselective medium) decreased from 10(8) to 10(7) CFU/ml. On the other hand, culturable counts measured by desoxycholate-hydrogen sulfite-lactose (DHL) agar (selective medium) were decreased from 10(8) to 10(4) CFU/ml by the same treatment. The results suggest that 99.9% of Salmonella Enteritidis detected on TSA were injured but recoverable. When injured Salmonella Enteritidis was incubated in TSB, the culturable count measured by TSA did not increase for 2 h, whereas that by DHL agar increased after incubation for 30 min. After incubation for 2 h, the culturable count measured by DHL agar reached a similar level with that by TSA, indicating that Salmonella Enteritidis had recovered. The two-dimensional polyacrylamide gel electrophoresis analysis revealed that elongation factor G (FusA) and pyruvate kinase (PykF) specifically increased in the cells just after heat treatment and in the recovery cells. The levels of transcription of 86 stress-inducible genes were also investigated by reverse transcription PCR. Nineteen heat-inducible (clpB, clpX, degP, dnaJ, fkpA, ftsJ, gapA, hflB, hslJ, hslU, hslV, htpG, htrA, lon, mopA, mopB, mreB, rpoE, and ppiD), and 12 oxidative-stress and DNA damage-inducible (ahpC, ahpF, fldB, fur, grxA, dinF, katG, mutM, recA, soxR, trxC, and zwf) genes were transcribed extensively during recovery in TSB. The results obtained in this study will be used to develop the media or culture conditions that will promote recovery for the detection of food poisoning bacteria, including injured cells from food products.