Characteristics of the serum pepsinogen (Pg) test, and the relationship between Pg test results and gastric cancer outcomes.

BACKGROUND AND AIMS: The serum pepsinogen (Pg) test is considered to be a high-risk marker for gastric cancer, so that it is intended that it will be gradually adopted for mass surveys in Japan. This manuscript examines the characteristics of the preoperative Pg test and the relationship between its results and the postoperative outcomes of gastric cancer cases in relation to the neutrophil/lymphocyte ratio (NLR) as a prognostic -marker. MATERIALS AND METHODS: Peripheral blood samples were taken within 1 week before gastrectomy for the Pg test and NLR. RESULTS: The Pg test identified 128 (+) cases (59.0%) and 89 (-) cases (41.0%). In three of all cases, cancer had not been detected by an upper gastrointestinal series (UGI) in the previous year (every case showed Pg (+)). Five-year survival was 80.5% in the Pg (+) group, 60.7% in the Pg (-) group, 85.6% in the NLR (<5.0) group, and 29.9% in the NLR (5.0) group, but 14.3% in the NLR (5.0) plus Pg (-) group, and 89.5% in the NLR (<5.0) plus Pg (+) group. The differences in the 5-year survivals were statistically significant. CONCLUSIONS: A mass survey using the Pg test alone is inadequate, but the Pg test may be an important adjunct to the conventional methods. Gastric cancer with Pg (-) may have a higher potential for malignancy than cancer with Pg (+).

Esophageal fibrovascular polyp removed by cervical esophagotomy.

We report a case of esophageal fibrovascular polyp (FVP) removed by cervical esophagotomy. The patient was a 74-year-old man in whom an intraesophageal mass was detected by a chest CT examination during a complete medical check-up. An upper gastrointestinal series showed a large, pedunculated, cervical esophageal mass for which our preoperative diagnosis was a FVP. We studied its features, as well as removal procedures in 45 patients in the literature. Most patients had marked symptoms, but ours had no complaints, and so this case may be a rare one. Various removal procedures were reported, but thoracotomy and esophagectomy are considered to be the inappropriate procedures since FVP is a benign disorder.

Abdominal stapled side-to-end anastomosis (Baker type) in low and high anterior resection: experiences and results in 69 consecutive patients at a regional general hospital in Japan.

OBJECTIVE: The technique of transanally introducing a circular stapled device to accomplish colorectal anastomoses has been widely used. However, the widespread popularity of this technique may have created the potential of anal sphincter injury during transanal insertion of the anastomosing stapler. Thus, to avoid the risk of anal sphincter injury during anal manipulation, we have been performing an abdominal approach, namely abdominal stapled side-to-end anastomosis (ASSEA) using a Purstring and premium curved EEA stapler in low and high anterior resection. This study will present our experience and results of consecutive resections. METHODS: ASSEA following a resection of the rectum and sigmoid colon for carcinomas was consecutively performed between October 1998 and May 2002. Age, sex, pre-operative anal function, the TNM classification by the UICC rules, operative methods, postoperative morbidity, mortality, anal function and bowel frequency were evaluated. RESULTS: Sixty-nine consecutive patients underwent a resection of the rectum and sigmoid colon with ASSEA. There were three (4.3%) clinical anastomotic leakages in the cases studied. Anastomoses that were located above the peritoneal reflection leaked in one (2.5%) of 40 cases, while anastomoses below the peritoneal reflection leaked in two (6.9%) of 29 cases. A diverting stoma was performed in five (17%) of the 29 cases with low anastomosis. Postoperative anal function was stable without soiling or faecal leakage and bowel frequency two months after surgery was less than four times in all 61 patients. There was no postoperative mortality related to the anastomosis. CONCLUSIONS: Abdominal stapled side-to-end anastomosis (Baker type) was found to be a safe and relatively easy method in both low and high anterior resection in association with a good quality of life.

Transperitoneal drainage for a large cystic degeneration after regression of an intra-abdominal desmoid tumor.

A new technique is described for treating a large cystic degeneration after regression of an intra-abdominal desmoid tumors in patients with familial adenomatous polyposis. A cysto-peritoneal shunt is made for the relief of large cystic degeneration by creating a channel between the mesenteric cyst and the peritoneal cavity by means of a silicone tube to facilitate transperitoneal drainage.

Desmoplastic response in biopsy specimens of early colorectal carcinoma is predictive of deep submucosal invasion.

PURPOSE: The aim of this study was to evaluate the role of histopathology of biopsy specimens in predicting depth of infiltration in early colorectal carcinomas before treatment. METHODS: Early colorectal carcinomas that had been resected surgically or endoscopically between 1984 and 1995 were analyzed. Histopathologic findings, including differentiation of adenocarcinoma and a desmoplastic response were investigated. RESULTS: One hundred nine early colorectal carcinomas consisted of 73 lesions of carcinoma in situ, 13 submucosal carcinomas with minimum invasion, 8 lesions with moderate invasion, and 15 lesions with deep invasion. Of 73 carcinoma in situ lesions, 72 (approximately 99 percent) showed well-differentiated adenocarcinomas and no desmoplastic response. Twelve (92 percent) of 13 submucosal carcinomas with minimum invasion also revealed well-differentiated adenocarcinoma without a desmoplastic response. Sixty-three percent (5/8) of lesions with moderate invasion revealed well-differentiated adenocarcinoma. None of the lesions had a desmoplastic response. Among lesions with deep invasion, 73 percent (11/15) demonstrated moderately differentiated adenocarcinoma, and 11 lesions had a prominent desmoplastic response (73 percent; P < 0.01). CONCLUSIONS: These results suggest that if histopathologic findings of biopsy specimens taken from them before treatment demonstrated adenocarcinoma associated with a desmoplastic response, the lesions had at least deep invasion carcinomas. These lesions should be resected surgically. Submucosal carcinomas with minimum invasion, which have no desmoplastic response, could be treated endoscopically.

Further ST elevation at reperfusion by direct percutaneous transluminal coronary angioplasty predicts poor recovery of left ventricular systolic function in anterior wall AMI.

Some patients with acute myocardial infarction (AMI) develop further ST elevation at reperfusion by percutaneous transluminal coronary angioplasty (PTCA). This study reports the ST deviation at reperfusion by direct PTCA in relation to the clinical factors and the recovery of left ventricular (LV) systolic function. Fifty-two patients with anterior wall AMI were treated with direct PTCA. They were classified into the following 3 groups according to the change in ST elevation at reperfusion: increase of > or = 20% (ST reelevation); reduction of > or = 20% (ST resolution); and the other (ST no change). Angina pectoris preceding AMI occurred less often in the ST reelevation group (ST reelevation group, 38%; ST no change group, 81%; ST resolution group, 70%; p < 0.05). Recovery of LV ejection fraction during the first month after direct PTCA was significantly poor in the ST reelevation group in contrast to the ST resolution group (ST reelevation group, -6.3 +/- 13%; ST no change group, 18 +/- 20%; ST resolution group, 45 +/- 29%; p < 0.0001). The change in ST elevation at reperfusion was an index predicting the recovery of LV systolic function in the reperfusion by direct PTCA.

Prednisolone therapy for intra-abdominal desmoid tumors in a patient with familial adenomatous polyposis.

The management of intra-abdominal desmoid tumors in patients with familial adenomatous polyposis (FAP) is very difficult. Non-steroidal anti-inflammatory drugs (NSAIDs), anti-estrogenic agents, and steroids are most commonly used, because surgical removal of these tumors may result in severe morbidity, with local recurrence being common. We report a patient with FAP and intra-abdominal desmoid tumors that regressed markedly after prednisolone therapy. The patient, a 38-year-old woman, had undergone total colectomy and ileorectal anastomosis with a diagnosis of FAP with colon cancer. Approximately 17 months after the surgery, she noticed an elastic firm lump in the abdominal wall. She also experienced lower abdominal distension. Computed tomography (CT) of the lower abdomen showed an invasive heterogenous low-density mass occupying the intra-abdominal space. She was treated with sulindac, NSAID, at 300 mg/day, the diagnosis being intra-abdominal desmoid tumors. She exhibited an intestinal obstruction about 9 months after the initiation of sulindac therapy. We changed the treatment and began prednisolone (initial dose, 40 mg/day). This treatment was continued for two years; subsequently, the lesions regressed markedly. She is currently well, more than 3 years after the withdrawal of prednisolone.

Delayed improvement in skeletal muscle metabolism and exercise capacity in patients with mitral stenosis following immediate hemodynamic amelioration by percutaneous transvenous mitral commissurotomy.

The abrupt improvement in hemodynamics after successful percutaneous transvenous mitral commissurotomy (PTMC) does not immediately enhance exercise capacity. Improved exercise capacity several months after PTMC has been reported. We hypothesized that the delayed improvement in exercise capacity is due partly to the slow improvement in the metabolism of skeletal muscle. This study examined the short- and long-term effects of PTMC on exercise capacity and skeletal muscle metabolism in patients with mitral stenosis. Treadmill exercise testing with respiratory gas analysis was performed in 11 patients with symptomatic mitral stenosis before and 3, 30, and 90 days after successful PTMC. On the same schedule, forearm metabolism of high-energy phosphates was measured by magnetic resonance spectroscopy during and after handgrip exercise. Ten healthy volunteers were examined. PTMC resulted in an immediate symptomatic improvement. However, exercise capacity and skeletal muscle metabolism remained unchanged 3 days after PTMC. At 30 days after PTMC, there were significant improvements in peak oxygen consumption (p <0.05), intracellular pH at end-exercise (p <0.05), and time constant for phosphocreatine recovery (mean +/- SD 88.9 +/- 11.3 vs 106.3 +/- 11.7 seconds, p <0.01) compared with these baseline values. These improvements remained even at 90 days after PTMC. Exercise capacity improved with some time delay after immediate hemodynamic amelioration by PTMC. Long-term improvement in exercise capacity depends partly on the slowly progressing improvement in skeletal muscle metabolism after long-standing mitral stenosis.

Diverticular disease of the colon at a regional general hospital in Japan.

PURPOSE: X-ray film registry records were reviewed to better understand the changing nature of diverticular disease (DD) of the colon in Japan. RESULTS: Among 6,849 patients undergoing barium enema examination during a eight-year period from 1985 to 1992, this condition was found in 1,074 patients (15.7 percent), including 702 males (65.4 percent) and 372 females (34.6 percent). During this eight-year period there was an increase in frequency from 10.7 percent in 1985 to 17.8 percent in 1992. The proportion of patients with right-sided, bilateral, and left-sided DD was 69.2 percent, 17.5 percent, and 13.3 percent, respectively. The right-sided DD was more common in the younger age group and was predominant in male patients, whereas the left-sided DD increased with age, especially in female patients. Of the 1,074 patients, 11 (1.0 percent) underwent surgery in the same period. Regarding the right-sided DD, only 2 of 743 patients received surgery (0.3 percent). On the other hand, of the 143 patients with left-sided DD, 9 patients (6.3 percent) received some form of surgery. CONCLUSION: Right-sided diverticular disease of the colon is still common in Japan. It does not appear that this tendency will change in the future. Nearly all patients diagnosed as having diverticula had either no symptoms or only mild symptoms, and only about 1 percent required surgery. Right-sided diverticular disease of the colon seems to have had no serious clinical problems compared with left-sided DD.

Role of skeletal muscle metabolism in exercise capacity of patients with myocardial infarction studied by phosphorus-31 nuclear magnetic resonance.

Patients with congestive heart failure reportedly show a poor correlation between cardiac function and exercise tolerance. Recent studies have demonstrated that skeletal muscle is the main factor that limits exercise tolerance. However, the relationship between high-energy phosphate metabolism in skeletal muscle and exercise tolerance has not been well defined. Exercise capacity was assessed in 35 subjects with myocardial infarction in terms of peak oxygen consumption (peak VO2) during treadmill exercise with an analysis of expired gases. On the same day, changes in high-energy phosphates in finger flexor muscle during handgrip exercise were measured by magnetic resonance spectrometry. Phosphocreatine (PCr) utilization and the decrease in pH during handgrip exercise were significantly greater in patients with a poor exercise capacity and their time constant of recovery of PCr was prolonged. The ratios of PCr/Pi (Pi: inorganic phosphate) and PCr/HMPA (HMPA: hexamethylphosphoramide) during exercise and the time constant of recovery of PCr were significantly correlated with peak VO2. These results suggest that skeletal muscle metabolism governs exercise tolerance.

[Two separate surgical repairs of post-infarction blowout rupture of the left ventricular free wall and subsequently developed subepicardial aneurysm].

A 69-year-old female patient with acute myocardial infarction was admitted to our hospital. After i.v. administration of the rt-PA, echocardiography disclosed pericardial effusion to which pericardial drainage was performed first through subxiphoid incision. Immediately after the drainage, electromechanical dissociation emerged and emergency thoracotomy was performed. There was a small blowout rupture of the left ventricular free wall that was successfully repaired using single suture buttressed with Dacron felt without cardiopulmonary bypass support. On the 38th day after the surgery, cineangiography disclosed ventricular aneurysm, to which aneurysmectomy was performed under the cardiopulmonary bypass and her post operative progress was uneventful. Histological study of the resected specimen revealed so called subepicardial aneurysm. Although blowout rupture of the left ventricular free wall used to be lethal, there might be a chance of life saving even without cardiopulmonary bypass support, if the left thoracotomy could be done as quickly as possible.

[A case of supravalvular pulmonary stenosis associated with Noonan's syndrome: usefulness of Doty's operation].

A twelve-year-old boy associated with Noonan's syndrome is reported. He had supravalvular pulmonary stenosis with a very high right-ventricular pressure, higher than that of systemic. Surgical treatment was performed to the supravalvular pulmonary stenosis with the technique of Doty's operation for supravalvular aortic stenosis, brought an excellent results. The gradient between the right ventricle and the pulmonary artery fell from 97 mmHg to 30 mmHg. The residual gradient is caused by functional infundibular stenosis. Doty's operation is a useful method for the operation of severe supravalvular pulmonary stenosis, too.

[Clinical experience of the Greenfield filter--especially about tilting and distal migration of the filters].

Since December 1985, we used Greenfield filter in 8 patients to prevent pulmonary embolism. Mean follow-up period was 42 month. Recurrence of pulmonary embolism was suspected in one patient after perfusion lung scan. Another patient died from other reasons. Occlusion of the inferior vena cava was not suspected in any patient clinically. Tilting and distal migration of the filters occurred frequently. 3 filters tilted greater than 5 degrees compared with the position immediately after their placement. 5 filters migrated distally more than half the length of a lumbar vertebra. Although there was no severe complications in our series, we should pay attention especially to the position and angle of the filters, since an extreme tilting position of the filter could be a possible cause of serious complications.

[A case report of early prosthetic valve endocarditis due to methicillin resistant Staphylococcus aureus infection--an experience of intraatrial implantation of mitral prosthesis with a Gore-Tex flange].

A 60-year-old female with mitral stenosis developed prosthetic valve endocarditis due to methicillin resistant staphylococcus aureus septicemia 3 weeks after mitral valve replacement. In vitro test disclosed susceptibility to minocycline and clindamycin. Despite large amount of intravenous administration, progressive heart failure due to massive perivalvular leakage occurred as a consequence of persisting infection. An emergent operation revealed valve detachment of the posterior portion resulting from ring abscess formation. A mitral prosthesis with a Gore-Tex flange was implanted partially in the left atrium just above the mitral ring and sutured to the atrial wall. Postoperative relapse was not detected even after discontinuing antibiotics. Prosthetic valve endocarditis due to methicillin resistant staphylococcus aureus is highly resistant to antibiotic therapy and likely to develop valve ring abscess. Prompt surgical treatment is mandatory in this situation.

[Surgical therapy for WPW syndrome combined with paroxysmal atrial tachycardia].

A 47-years old man presented with life-threatening paroxysmal supraventricular tachycardia. Electrophysiological study revealed both paroxysmal atrial tachycardia and atrioventricular reentrant tachycardia. The earliest site of activation during paroxysmal atrial tachycardia was located on the cranial portion of the left atrium and just behind the aorta. The atrioventricular accessory passway was located at the posterolateral wall of the left ventricle. Cryosurgical ablation was performed to the cranial portion of the left atrium and the accessory passway was interrupted from inside of the left atrium under the cardiopulmonary bypass. In the postoperative electrophysiological study, neither atrial tachycardia nor atrioventricular reentrant tachycardias was inducible. Since then he has never experienced tachycardia attack for one year.

[A case of tetralogy of Fallot with pulmonary aneurysm].

A case of pulmonary artery aneurysm associated with tetralogy of Fallot is presented. A 28-year-old man was admitted for evaluation of cyanosis and cardiac murmur. Preoperative angiography revealed tetralogy of Fallot and an aneurysm of the main pulmonary artery aneurysm. Operation consisted of pulmonary artery aneurysmectomy and total correction of the tetralogy of Fallot. Microscopic examination of the resected aneurysm showed the thickening of intima and fragmented elastic fibers of media. A brief review of the literature emphasizes the necessity of the surgical intervention.