Gastric and Bone Metastases Arising from Invasive Lobular Carcinoma With Ductal Carcinoma Occurring in one Breast Synchronously.

BACKGROUND/AIM: We report the case of a patient with gastric and bone metastases arising from an invasive lobular carcinoma of the breast coexisting with ductal carcinoma at the same time. CASE REPORT: A 68-year-old woman with gastric and right costal tumors was referred to our hospital. Esophagogastroduodenoscopy (EGD) revealed irregular, slightly elevated lesions extending from the gastric body to the antrum, and biopsy specimens revealed a poorly differentiated adenocarcinoma. Furthermore, abdominal contrast-enhanced computed tomography (CT) revealed extensive wall thickening with homogeneous enhancement in the stomach. 18F-2-deoxy-2-fluoro-glucose positron emission tomography (FDG-PET) showed intense FDG uptake in the right mammary gland and right third rib. Moreover, fine-needle aspiration of the third right rib lump and the right breast mass lesion was performed, and subsequent pathological investigations revealed metastatic adenocarcinoma and invasive ductal carcinoma, respectively. Immunohistochemical examination revealed that estrogen receptor was strongly positive (>95%) in breast cancer and focally positive (<5%) in gastric cancer with bone metastasis. In addition, another right breast tumor was detected by breast magnetic resonance imaging (MRI), and biopsy revealed invasive lobular carcinoma that matched the histological findings of bone and gastric lesions, including immunohistochemical examination. The patient was treated with an aromatase inhibitor, a CDK4/6 inhibitor, and a receptor activator of nuclear factor-kappa B ligand (RANKL) monoclonal antibody. She showed no symptoms or disease progression at 9-month follow-up after the initiation of systemic drug treatment. CONCLUSION: Invasive lobular carcinoma can metastasize to the gastrointestinal tract, and new treatment developments are expected as more cases will accumulate in the future.

Evaluation of Perioperative Intestinal Motility Using a Newly Developed Real-Time Monitoring System During Surgery.

BACKGROUND: This study aimed to investigate perioperative intestinal motility using a novel bowel sound monitoring system in patients undergoing breast and neck surgery. MATERIALS AND METHODS: This study enrolled 52 patients who underwent surgery for breast cancer, thyroid tumor, and parathyroid tumor at Kochi Medical School from May 2019 to June 2020. Perioperative bowel sound counts (BSCs) were recorded using a newly developed real-time analysis system in the operating theater. Clinical information and BSC per minute (cpm) data during the preanesthetic, preoperative, operative, postoperative periods, and period in recovery room were obtained to compare between each period. The Mann-Whitney U and Pearson Chi-square tests were used in data analysis. RESULTS: The BSCs during the intraoperative period and postoperative period were significantly decreased compared to those during the preanesthetic period (0.07 cpm versus [vs.]. 1.4 cpm, P = 0.002 and 0.1 cpm vs. 1.4 cpm, P = 0.025, respectively). The preoperative BSC with a preanesthetic BSC < 1.4 was significantly lower than that with a preanesthetic BSC ≥ 1.4 (0.40 cpm vs. 1.78 cpm, P = 0.006). The preanesthetic, preoperative, and postoperative BSCs with an intraoperative BSC < 0.07 were significantly lower than those with an intraoperative BSC ≥ 0.07 (0.48 cpm vs. 2.83 cpm, P = 0.007; 0.40 cpm vs. 1.81 cpm, P = 0.008; and 0.07 cpm vs. 0.42 cpm, P = 0.006, respectively). CONCLUSION: The real-time bowel sound analysis system demonstrated an inhibitory effect associated with anesthetic and surgical stress on intestinal motility as the BSC sequentially.

Evaluation of Follow-up Examinations Using Ultrasonography for Patients With Thyroid Nodules Initially Diagnosed as Benign.

BACKGROUND/AIM: The aim of this study was to determine the natural history of benign thyroid nodules using ultrasonography. PATIENTS AND METHODS: The records of 223 patients with benign thyroid nodules treated at the Kochi Medical School from 2010 to 2012 were reviewed retrospectively. Repeated ultrasonography was performed, and the findings were directly compared with previous images. RESULTS: The median change in the size of the nodules was 0.01 cm/year, although the size of six nodules (2.7%) increased more than 0.5 cm/year, and these nodules were removed surgically. Nineteen patients (8.5%) underwent surgery during the follow-up period. Compared to those who did not undergo surgery, the size of the nodules was larger and the rate of change in nodule diameter was higher in those undergoing surgery. The pathological diagnosis based on repeated fine needle aspiration cytology was benign nodules in 16 patients and papillary cancer in three patients. CONCLUSION: Even if a thyroid nodule is initially diagnosed as benign, it may have malignant potential. Therefore, so as not to miss malignancies, nodules should be carefully re-evaluated to assess their growth or change in size using ultrasonography.

[A Case of Early-Onset Breast Cancer for Which the Operative Indication for Breast Conservation Was Based on BRCA Genetic Testing].

We report a case of a patient with early-onset breast cancer who decided to undergo adaptation for breast-conserving surgery based on the results of genetic testing. A 25-year-old woman became aware of a lump in her left breast and visited a nearby hospital, where she was diagnosed with breast cancer. She has no personal history. Her paternal grandfather was diagnosed with rectal cancer at age 60. Ultrasonography revealed an irregularly-shaped hypoechoic mass measuring 3.8 cm in the C area of her left breast and an enlarged lymph node 2.0 cm in diameter in the left axillary area. The breast tumor was pathologically diagnosed as invasive ductal carcinoma by core needle biopsy and was immunohistochemically characterized as ER(-), PgR(-), and HER2(-), s o-called triple negative. Moreover, lymph node metastasis was confirmed by fine needle aspiration cytology. She underwent neoadjuvant chemotherapy and achieved a clinical complete response. A woman with early-onset triple negative breast cancer has a high probability of hereditary breast and ovarian cancer, with a high risk of ipsilateral second breast cancer after conserving surgery. Thus, BRCA genetic testing may be necessary before surgery. As no pathogenic mutation wasfound in BRCA 1/2 in this case, the patient underwent breast-conserving surgery followed by radiation therapy for the conserved breast. The patient remained healthy and without any recurrence 4 years and 2 months after surgery.

Gastric outlet obstruction caused by metastatic tumor of the stomach originating from primary breast cancer: A case report.

The most common sites of breast cancer metastasis are the bone, liver, lung and brain, while gastrointestinal metastasis from breast cancer is rare. We herein present the case of a 68-year-old woman who was admitted to our department with nausea and appetite loss. The patient's medical history included right mastectomy with sentinel lymph node biopsy 5 years earlier for invasive lobular carcinoma, measuring 6.2 cm in greatest diameter, without lymphovascular invasion. Two years after the surgery, the patient developed brain metastasis and underwent metastasectomy to control the neurological symptoms, including unsteadiness and asthenia. After the second surgery, the patient received systemic chemotherapy using S-1, followed by bevacizumab plus paclitaxel. However, due to bevacizumab-related cardiotoxicity, the treatment was switched to eribulin. On esophagogastroduodenoscopy, an elevated lesion was identified in the antrum, causing severe narrowing of the gastric outlet. Biopsy and histological examination of the tumor revealed infiltration of the gastric wall by undifferentiated neoplastic cells with poor adhesion, morphologically similar to invasive lobular carcinoma, and immunohistochemical staining was positive for estrogen receptor, mammaglobin and GATA3. Finally, 18F-2-deoxy-2-fluoro-D-glucose (FDG) positron emission tomography combined with computed tomography imaging revealed FDG uptake across the thickness of the antral wall. The patient was diagnosed with gastric metastasis from the original breast cancer and subsequently underwent endoscopic self-expandable metallic stent (SEMS) placement. There were no procedure-related adverse events, and the patient remained alive under best supportive care 4 months after SEMS placement. To the best of our knowledge, this is the first reported case of gastric outlet obstruction caused by metastatic breast carcinoma managed by SEMS placement. While such a diagnosis is rare, clinicians treating patients with gastric metastases should be aware of possible gastric outlet obstruction and SEMS placement as an effective palliative intervention.

Spontaneous rupture of abdominal wall after breast reconstruction using deep inferior epigastric perforator flap following mastectomy for breast cancer.

BACKGROUND: The demand for breast reconstruction after mastectomy is rising. The use of deep inferior epigastric perforator (DIEP) flap in autologous reconstruction is a popular approach. There were some reports about abdominal complications after breast reconstruction. However, there was no report about spontaneous rupture of abdominal wall. CASE PRESENTATION: A 46-year-old female patient was diagnosed with left breast cancer. Left mastectomy with sentinel lymph node biopsy was performed, and the breast was reconstructed using DIEP flap simultaneously. She suffered heavy abdominal pain and vomiting at postoperative day 4. Computed tomography showed bowel herniation into the subcutaneous tissue caused by left abdominal wall rupture. The abdominal wall was sutured and repaired using mesh by emergency surgery. CONCLUSIONS: To the best of our knowledge, this is the first case about spontaneous rupture of abdominal wall after breast reconstruction using DIEP flap to be reported in the English literature. DIEP flap on breast reconstructive surgery may cause spontaneous rupture of abdominal wall.

A Novel Color Fluorescence Navigation System for Intraoperative Transcutaneous Lymphatic Mapping and Resection of Sentinel Lymph Nodes in Breast Cancer: Comparison with the Combination of Gamma Probe Scanning and Visible Dye Methods.

BACKGROUND: This study evaluated the clinical efficacy of a novel imaging system (HyperEye Medical System [HEMS]; Mizuho Corp., Tokyo, Japan) that uses the near-infrared (NIR) fluorescence of indocyanine green to analyze sentinel lymph node (SLN) biopsies for the staging of breast cancer. METHODS: This study enrolled 91 patients with histologically confirmed breast cancer that was clinically node negative with a tumor size <3 cm. We compared SLN identification rates between HEMS and conventional methods (gamma probe scanning using a colloidal radioisotope [RI] and a blue dye method) by analyzing the relationships of lymphatic to axillary lesions and SLNs. RESULTS: The identification rate of SLNs was 100% using HEMS, 97.8% using the RI method, and 95.6% using the blue dye method. Two types of lymphatic pathway (LP) were detected in 39 patients (42.9%) and also clearly identified using HEMS-captured color and NIR fluorescence. The incidence of two or more SLNs was significantly higher in patients with a two-route LP to the axilla group than in those with only one route (p < 0.001; 43.6 vs. 9.6%). CONCLUSIONS: The HEMS NIR fluorescence color imaging method is a promising potential modality for higher-level identification of SLNs than a standard combination of the RI and blue dye methods.

Clinical presentation and treatment of gastric metastasis from other malignancies of solid organs.

The aim of the present study was to analyze the clinicopathologic features and treatment outcomes of gastric metastasis from other malignancies of solid organs. A review was conducted of patients with metastatic tumors in the stomach from other malignancies of solid organs detected endoscopically at the Department of Surgery, Kochi Medical School, from January 1991 to December 2015. Seven patients (four men and three women), with a median age of 64 years (range, 42-71 years), had metastatic gastric tumors. Median tumor size was 7.3 cm (range, 2.5-12.0 cm). The primary malignancy leading to metastatic tumors in the stomach was esophageal cancer in three patients, breast cancer in two patients, renal cell carcinoma in one patient, and ovarian cancer in one patient. Gastric metastasis presented as solitary lesions in six patients and as multiple lesions in one patient. Four patients had solitary gastric metastasis, whereas three had multiple metastases in other organs. The median tumor size was significantly smaller in patients with solitary rather than multiple metastases (4.6 vs. 12.0 cm, respectively; P=0.038). Three patients received systemic therapy and four underwent surgical resection of the metastatic tumor, and of these, only one was alive 58 months after surgery. Clinicians should be aware of the possible existence of metastatic gastric cancer, especially in breast carcinoma and esophageal cancer. Surgical resection may considerably improve patients' quality of life, and could be of benefit when there is a risk of bleeding and/or a solitary metastasis.

Evaluation of the minimally invasive parathyroidectomy in patients with primary hyperparathyroidism: A retrospective cohort study.

INTRODUCTION: An accurate differential diagnosis between single adenoma (SA) and multiglandular disease (MGD) remains difficult in Technetium-99m sestamibi scintigraphy (MIBI)-negative patients with primary hyperparathyroidism (PHPT). The aim of the present study was to evaluate the minimally invasive parathyroidectomy (MIP) in patients with PHPT. METHODS: Clinical records of 48 patients who underwent neck exploration between November 2002 and June 2012 in Kochi Medical School Hospital were reviewed retrospectively to identify candidates that underwent for MIP which was defined as the selective removal of a SA using less invasive surgery. RESULTS: The preoperative detection rate of lesions using ultrasonography, MIBI, computed tomography, and magnetic resonance imaging was 90%, 83%, 76%, and 55%, respectively. Although all 39 patients in the MIBI-positive group were diagnosed with an SA and subsequently underwent curative MIP, 3 patients in MIBI-negative group (n = 6) were MGD, who underwent neck exploration. Preoperative mean intact parathyroid hormone (419 pg/ml vs. 149 pg/ml; P < 0.01) and alkaline phosphatase levels (746 U/l vs. 277 U/l; P < 0.01) were significantly higher in the SA than MGD group. CONCLUSIONS: In MIBI-negative patients with indications for surgery, MIP should not be carried out without a clear localization of SA, or in MGD.

[Is the LHRH Agonist Recommended for Fertility Preservation ?].

The POEMS reportedan effect of goserelin for fertility preservation. The Clinical Practice Guideline for Breast Cancer by The Japanese Breast Cancer Society indicates that the use of the LHRH agonist (LHRHa) for preventing chemotherapy-induced early menopause is a grade C-1 recommendation, and its use for fertility preservation is a grade C-2 recommendation. Results from previous studies on the effects of LHRHa for fertility preservation have varied owing to differences in chemotherapy regimens, definitions of ovarian failure, and dosages of tamoxifen. In the POEMS, the primary endpoint of ovarian failure at 2 years was significantly lower, and the secondary endpoint of pregnancy outcomes was better in the combination group; however, precise interpretation is difficult because many cases were excluded. Currently, it is not necessary to revise The Clinical Practice Guideline; however, desirable results from future studies may allow the recommendation of a specific dosage of LHRHa for fertility preservation.

Intensive versus intermediate glucose control in surgical intensive care unit patients.

OBJECTIVE: The optimal perioperative blood glucose range to improve surgical site infection (SSI) in surgical intensive care unit (ICU) patients remains unclear. We sought to determine whether the incidence of SSI is reduced by perioperative intensive insulin therapy (IT). RESEARCH DESIGN AND METHODS: Patients were randomly assigned to receive perioperative intensive IT, with a target blood glucose range of 4.4-6.1 mmol/L, or intermediate IT, with a target blood glucose range of 7.7-10.0 mmol/L in the surgical ICU. We defined the primary end point as the incidence of SSI. RESULTS: Study participants were randomly assigned to glucose control with one of two target ranges: for 225 patients in the intermediate IT group or for 222 patients in the intensive IT group, respectively. No patients in either group became hypoglycemic (<4.4 mmol/L) during their stay in the surgical ICU. In our series, the rate of SSI after hepato-biliary-pancreatic surgery was 6.7%. Patients in the intensive IT group, compared with the intermediate IT group, had fewer postoperative SSIs (9.8% vs. 4.1%, P = 0.028) and a lower incidence of postoperative pancreatic fistula after pancreatic resection (P = 0.040). The length of hospitalization required for patients in the intensive IT group was significantly shorter than that in the intermediate IT group (P = 0.017). CONCLUSIONS: We found that intensive IT decreased the incidence of SSI among patients who underwent hepato-biliary-pancreatic surgery: a blood glucose target of 4.4 to 6.1 mmol/L resulted in lower rate of SSI than did a target of 7.7-10.0 mmol/L.

Extrahepatic stem cells mobilized from the bone marrow by the supplementation of branched-chain amino acids ameliorate liver regeneration in an animal model.

BACKGROUND AND AIMS: In recent years, bone marrow (BM)-derived stem cell repopulation of injured organs has been increasingly observed; however, the extent to which it occurs and its clinical relevance remain unclear. Here, we investigated on the potential of extrahepatic stem cells to become hepatocytes using the treatment of the oral supplementation of branched-chain amino acids (BCAA). METHODS: In the first, Sprague-Dawley (SD) rats were administered BCAA to promote liver regeneration; in the second, syngenic liver transplantations using wild-type SD rats that do not express green fluorescent protein (GFP) as syngenic donors and GFP-transgenic SD rats as recipients to confirm that an extrahepatic source of cells (GFP(+)) could repopulate the transplanted (GFP(-)) liver were performed. RESULTS: Treatment of the oral supplementation of BCAA for 2-3 weeks before transplantation to promote liver regeneration resulted in greater than 7 days graft volume, with extensive spotty conversion of a small wild-type graft to the recipient GFP(+) genotype. The treatment by oral supplementation of BCAA resulted in higher levels of CD34+SDF+c-kit+ stem cells in the blood and liver after liver transplantation. Liver repopulation could be achieved with hepatocytes that bone marrow-derived from stem cells proliferated. CONCLUSIONS: We have identified extrahepatic stem cell migration from the BM to the injured liver as a mechanism underlying liver regeneration that supports hepatocyte proliferation in diseased liver. Our results suggested that BCAA is able to mobilize a population of BM-derived cells that contribute to hepatic regeneration.

Efficacy of laparoscopic gastric mobilization for esophagectomy: comparison with open thoraco-abdominal approach.

BACKGROUND: Less invasive esophagectomy using laparoscopic or thoracoscopic surgery has been reported to have the advantages in short-term recovery over the conventional open thoraco-abdominal approach. However, few reports directly compare laparoscopic gastric mobilization (LGM) and thoracotomy with laparotomy and thoracotomy. The aim of this study was to prove the clinical efficacy of LGM compared with open thoraco-abdominal esophagectomy (OE) in treating thoracic esophageal cancer. PATIENTS AND METHODS: We retrospectively reviewed 92 consecutive patients who underwent esophagectomy by OE (n=47) or LGM (n=45) between 1999 and 2009 at Kochi Medical School (Kochi, Japan) to analyze the surgical outcomes. RESULTS: Patients who underwent LGM had significantly lower operative blood loss (430 versus 1060 mL; P<.001), lower rate of postoperative infections (POIs) (33.3 versus 55.3%; P=.034), shorter length of intensive care unit stay (1 versus 3 days; P<.001), and hospital stay (35 versus 46 days; P=.003). CONCLUSIONS: LGM has clinical benefits compared with OE in reduced POIs and faster recovery for patients with esophageal cancer.

Oral supplementation of branched-chain amino acids reduces early recurrence after hepatic resection in patients with hepatocellular carcinoma: a prospective study.

PURPOSES: The long-term outcomes of branched-chain amino acids (BCAA) administration after hepatic resection in patients with hepatocellular carcinoma (HCC) remain unclear. This study assessed the effect of oral supplementation with BCAA on the development of liver tumorigenesis after hepatic resection in HCC patients. METHODS: Fifty-six patients were randomly assigned to receive either BCAA supplementation (Livact group, n = 26) or a conventional diet (Control group, n = 30). Twenty-six patients in the BCAA group were treated orally for 2 weeks before and 6 months after hepatic resection. Postoperative tumor recurrence was continuously evaluated in all patients by measuring various clinical parameters. RESULTS: There was no significant difference in the overall survival rate between the two patient groups; however, the recurrence rate at 30 months after surgery was significantly better in the Livact group in comparison to the Control group. Interestingly, the tumor markers, such as AFP and PIVKA-II, significantly decreased at 36 months after liver resection in the Livact group in comparison to the Control group. CONCLUSIONS: Oral supplementation of BCAA reduces early recurrence after hepatic resection in patients with HCC. This treatment regimen offers potential benefits for clinical use in such patients, even in cases with a well-preserved preoperative liver function.

PKIB expression strongly correlated with phosphorylated Akt expression in breast cancers and also with triple-negative breast cancer subtype.

The cAMP-dependent protein kinase inhibitor-ß (PKIB) is presumed to be one of the regulatory factors controlling the cAMP-dependent protein kinase A signaling pathway. The aim of this study was to investigate the frequency and patterns of PKIB overexpression in human breast cancer. We also examined the relationship between PKIB and phosphorylated Akt (pAkt) expression in the tumors. Using immunohistochemical techniques, we examined the expression of PKIB, ER, PR, HER2, and pAkt in 148 primary human breast carcinomas. We then analyzed the relationships between PKIB expression and that of pAkt, ER, PR, and HER2, as well as between PKIB expression and various clinicopathological characteristics. We assessed 64 and 27 cases, respectively, as positive for either PKIB or pAkt expression; 20 cases were positive for both PKIB and pAkt. We observed a significant positive correlation between the expression of PKIB and that of pAkt (P = 0.006). We showed by immunohistochemical analyses that PKIB expression was positively correlated with triple-negative breast cancers (P = 0.0004). These findings provide evidence for PKIB overexpression associated with pAkt expression. Furthermore, PKIB expression was strongly correlated with triple-negative breast cancer, suggesting that PKIB expression might contribute to the tumor behavior and development of breast cancer.

Branched-chain amino acid-enriched nutrients stimulate antioxidant DNA repair in a rat model of liver injury induced by carbon tetrachloride.

Oxidative stress (OS) plays an important role in the progression of chronic liver disease including organ injury and hypoalbuminemia. Long-term oral supplementation with branched-chain amino acids (BCAAs) can inhibit liver dysfunction but their role in the prevention of liver fibrosis and injury to the liver is unclear. The aim of this study was to assess how BCAAs preserve liver function from OS. To investigate how BCAAs specifically prevent OS, we evaluated the effect of oral supplementation with BCAAs on OS using a rat liver cirrhosis model. Liver cirrhosis was induced in ten male Sprague-Dawley rats by administering carbon tetrachloride for 12 weeks. Five of the ten carbon tetrachloride-treated rats were assigned to a control group and five to a BCAA group. BCAA-supplementation significantly preserved plasma albumin concentrations and significantly inhibited the occurrence of organ injury as determined by blood chemistry analysis. Hepatic expression of OGG1 mRNA was increased in the BCAA group compared to the control group. In the BCAA group, increased hepatic levels of OGG1 protein were found by western blot. On the other hand, the number of 8-OHdG-positive cells was significantly higher in liver sections taken 1 month after carbon tetrachloride treatment. Furthermore, OGG1-positive cells were significantly increased in the hepatocytes around the central vein. BCAA was found to reduce OS, which could possibly lead to a decrease in the occurrence of hypoalbuminemia and organ injury. Our results indicate that BCAA-enriched nutrients stimulate antioxidant DNA repair in a rat model of liver injury induced by carbon tetrachloride.

The effect of the neutrophil elastase inhibitor sivelestat on early injury after liver resection.

BACKGROUND: The effects of sivelestat on endotoxin-induced lung injury, postperfusion lung injury, and ischemia-reperfusion are known, yet the benefits of sivelestat during liver surgery have yet to be elucidated. The aim of the present study was to assess the effects of sivelestat, with a focus on postoperative chemical data, in hepatectomized patients. PATIENTS AND METHODS: A prospective clinical study was conducted in 50 patients undergoing hepatic resection. Patients were randomly assigned to receive Elaspol, sivelestat (ELP group, n = 25) or placebo (control group, n = 25). Perioperative blood chemistry values in both groups, including high-mobility group box 1 (HMGB1) and interleukin (IL)-6, were monitored. RESULTS: The HMGB1 levels increased immediately after the operation (from the intraoperative period to the second postoperative day [POD]) in the control group. Compared to the control group, the levels of HMGB1 in the ELP group were significantly suppressed by the perioperative administration of sivelestat. At POD 1, the levels of IL-6 in the ELP group decreased more rapidly than those before the operation compared to the control group. CONCLUSIONS: A human clinical study demonstrated the effect of polymorphonuclear leukocyte elastase inhibitor on the earliest markers of liver injury. The present study showed that patients who received sivelestat had reduced release of HMGB1, and that IL-6 levels decreased more rapidly in patients treated with sivelestat than in those who received the placebo. The most appropriate dose, timing, and duration of sivelestat in humans remain unclear; however, it may have therapeutic potential for various liver injuries.

Effect of perioperative intensive insulin therapy for liver dysfunction after hepatic resection.

BACKGROUND: Intensive insulin therapy (IIT) reduces morbidity and mortality in patients in surgical care units, yet the benefits of IIT during liver surgery, especially on liver function after hepatic resection, are not known. The aim of the present study was to assess the effects of IIT, with a focus on postoperative liver function, in hepatectomized patients. METHODS: A total of 150 patients who underwent surgical management for hepatic diseases between September 2007 and March 2009 at Kochi Medical School were investigated. Patients were divided into two groups: (1) those receiving IIT via a closed-loop glycemic control system (i.e., an artificial pancreas; AP group; n = 74); or (2) those receiving conventional insulin therapy using the sliding scale method (SS group; n = 76). The targeted blood glucose zones in the AP and SS groups were 80­110 and 150­200 mg/dl, respectively. RESULTS: Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels increased and prothrombin time (%) decreased immediately after surgery in both groups. There was a significant difference in postoperative ALT levels between the two groups on postoperative days 1 and 6. Hepatocyte injury and changes in AST and ALT levels after surgery (compared with preoperative levels) were significantly greater in the SS group than AP group after liver resection. During the first 18 h after hepatic resection, 174 IU of insulin was required per patient for tight glycemic control with IIT. CONCLUSIONS: Perioperative IIT ameliorated liver dysfunction after hepatic resection. Liver regeneration and/or an antiinflammatory effect of IIT may underlie its protective effects against hepatocyte injury in hepatectomized patients.

Double tract reconstruction after distal gastrectomy for gastric cancer is effective in reducing reflux esophagitis and remnant gastritis with duodenal passage preservation.

BACKGROUND AND AIMS: So far, there have been no reports assessing double tract (DT) reconstruction after distal gastrectomy for gastric cancer, which maintains the duodenal passage of food. The aim of this study was to evaluate the clinical results of DT reconstruction compared with Roux-en-Y (RY) and Billroth I (BI) reconstruction following distal gastrectomy. PATIENTS AND METHODS: Outcomes following DT (33 patients), RY (38 patients), or BI (47 patients) reconstructions were investigated retrospectively. These outcomes included postoperative esophagogastroscopic findings, the angle of His measured from postoperative esophagogastrography, and the quality of life, determined by the Gastrointestinal Symptom Rating Scale (GSRS) 1 year after surgery. RESULTS: The degree and extent of gastritis was significantly lower in patients who had undergone DT or RY compared with BI reconstruction (P < 0.05). The angle of His was significantly greater in patients who had undergone BI rather than RY or DT reconstruction (P < 0.05) and was significantly greater in patients with reflux esophagitis (P < 0.05). Using the GSRS, patients who underwent DT or RY reconstructions had significantly lower reflux and indigestion than patients who had undergone BI reconstruction. The length of the lesser curvature of the remnant stomach did not differ significantly between the three reconstruction procedures. CONCLUSIONS: DT reconstruction following distal gastrectomy should be considered as a reconstruction technique as it allows future endoscopic investigation in cases with postoperative problems and results in low levels of reflux esophagitis and remnant gastritis.