Analysis of fat digestive and absorptive function after subtotal gastrectomy by a 13C-labeled mixed triglyceride breath test.

BACKGROUND/AIM: In the choice of reconstructions, digestive and absorptive disturbances, resulting in weight loss after subtotal gastrectomy, remain a problem. The aim of this study was to compare fat absorptive function after Billroth I (B-I) and Roux-en-Y (RY) reconstructions after subtotal gastrectomy for gastric cancer. METHODS: A (13)C-labeled mixed triglyceride breath test was performed in 31 patients after subtotal gastrectomy and in 15 healthy volunteers to assess fat digestive and absorptive function. Seventeen B-I reconstructions and 14 RY reconstructions were performed after subtotal gastrectomy. Fat digestive and absorptive function was determined by percent (13)CO(2) cumulative dose at 7 h. Relationship between fat absorptive function and perioperative factors were analyzed. RESULTS: Gender distribution, mean age, pathological staging, level of lymph node dissection, preservative procedure of the vagus nerve and mean follow-up period in the two surgical groups did not differ significantly. Only the type of reconstruction (p = 0.024) was associated with differences in fat digestive and absorptive function by univariate analysis: B-I reconstruction was superior to RY reconstruction. CONCLUSIONS: Fat digestive and absorptive function after B-I reconstruction was superior to that after RY reconstruction, probably because the B-I reconstruction was the procedure that permitted food passage through the duodenum.

[Combination of operation, chemotherapy and radiation for AFP producing gastric cancer--a case report].

We report a case of AFP producing gastric cancer after a combination of operation, chemotherapy and radiation. A 70-year-old man was admitted complaining of abdominal fullness. He was diagnosed as having type 3 advanced gastric cancer with multiple lymph node metastasis, including No. 8p lymph node, by endoscopy and computed tomography. Distal gastrectomy and D2 lymph node dissection were performed after chemotherapy using S-1, low-dose CDDP and CPT-11. Histopathological study showed moderately differentiated adenocarcinoma, and immunohistochemical study revealed a few AFP-positive tumor cells. Postoperatively, radiation (50 Gy) was performed for paraaortic lymph node metastasis and right hepatic lobectomy for liver metastasis. However, about 2 months after hepatic lobectomy, liver metastasis was diagnosed again by computed tomography, and radiation (30 Gy) was performed. He died 13 months after first surgery.

[A case of occult breast carcinoma with irradiation therapy and axillary lymph node dissection].

A 78-year-old woman was seen at the hospital for a swollen left axillary node. There was an elastic hard mass measuring 0.7 cm in diameter in the left axilla, but no breast mass was palpable in the bilateral breasts. Mammography did not reveal any tumor and calcification, and there was no abnormalities on breast ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI). Aspiration biopsy cytology of the left axillary node revealed adenocarcinoma. Systemic examination failed to reveal primary lesion. Thus, to make the diagnosis, we enucleated the axillary nodule. Immunohistochemical staining for the excisional specimen revealed an estrogen receptor, progesterone receptor and gross cystic disease fluid protein-15 (GCDFP-15) was strongly positive, so we diagnosed it as an occult breast carcinoma. After obtaining her informed consent, the patient underwent left axillary lymph node dissection and irradiation therapy of the left breast. The patient has been disease-free under adjuvant chemoendocrine therapy. We treated the occult breast carcinoma with radiation therapy of the breast and axillary lymph node dissection, and provided a review of the literature.

[A case of recurrent esophageal cancer responding to second-line chemotherapy of TS-1/docetaxel combination].

A 70-year-old man suffering from advanced esophageal cancer (Stage II) underwent subtotal esophagectomy in December 2000. He then had postoperative chemotherapy, called low-dose FP, and was followed in an ambulatory setting. In December 2003, he was diagnosed as a recurrence of esophageal cancer with multiple liver metastases and upper mediastinum lymph node, so he was treated by combined chemotherapy consisting of TS-1 and docetaxel as a second-line chemotherapy. After 3 courses of this therapy, CT scan showed that the size of liver and lymph node metastases was reduced and the effect of this therapy was PR. PR continued for about 6 months. This chemotherapy made it possible to treat liver and lymph node metastasis in an ambulatory setting. It is conceivable that this combination chemotherapy might be a promising regimen for a short period.

Duodenal cancer arising from the remaining duodenum after pylorus-preserving pancreatoduodenectomy for ampullary cancer in familial adenomatous polyposis.

We herein report a rare occurrence of duodenal cancer arising from the remaining duodenum after pylorus-preserving pancreatoduodenectomy for ampullary cancer in familial adenomatous polyposis (FAP). In this patient, proctocolectomy and ileoanal anastomosis for FAP had been performed 11 years earlier. During the current admission, the patient was diagnosed with adenocarcinoma in the Vater's ampulla using imaging and pathological examinations. In addition, a pylorus-preserving pancreatoduodenectomy was performed. The tumor was a well-differentiated tubular adenocarcinoma and no other polyps were identified in the duodenum by pathological examination. However, 1 year after surgery, a polypoid lesion measuring 15 x 15 mm was indicated in the remaining duodenum by endoscopic surveillance. This lesion was completely resected by endoscopic mucosal resection and the resected specimen revealed well-differentiated tubular adenocarcinoma in an adenomatous lesion. This report suggests that resection of the total duodenum is essential for duodenal neoplasms in FAP to prevent a recurrence in the remaining duodenum.

Surgical treatment of methicillin-resistant Staphylococcus aureus infection following infrainguinal arterial reconstruction.

A 64-year-old man was referred to our hospital with Methicillin-resistant Staphylococcus aureus (MRSA) infection following infrainguinal arterial reconstruction. As repeated MRSA sepsis occurred, we decided to remove the infected graft with distal revascularization via circuitous graft tunneling to avoid serious infections and allow limb salvage. An iliofemoro bypass was performed via an extra-anatomical bypass, from just below the iliac crest into the musculus quadriceps femoris using an 8 mm-ringed polyester gelatin polypropylene tube graft, with complete debridement of a groin infection. Postoperative 3-dimentional CT angiography revealed that the prostheses was patent and the patient had an uneventful postoperative course. We concluded that this extra-anatomical bypass was a safe procedure and an excellent option for patients with an infected vascular prosthetic graft in the groin after previous revascularization, like in our case with no available autogeneous vein grafts.

Fluorescent-based BAT-26 analysis for distinct screening of microsatellite instability in colorectal cancers.

For easy screening of genetic instability in colorectal cancers, we tried BAT-26 and BAT-25 mononucleotide repeats using fluorescent analysis and evaluated their usefulness and problems compared with other markers: D5S346, D17S250, D2S123, and D2S391, D4S392 (located near BAT-26 and BAT-25 respectively). The high-frequency of MSI (MSI-H) tumours, defined as tumours having instability in more than two markers, were detected in 8/146 (5.5%). These MSI-H cases were younger ages at diagnosis, and showed significantly higher incidences of right side location, and poorly differentiated histology than other cases (p<0.05). Four cases (2.7%) showed a 1 bp size shift in BAT-26 and 2 of them showed loss of heterozygosity (LOH) at D2S391 near BAT-26 locus. Among 9 cases with a 1 bp size shift in BAT-25, 6 cases showed LOH at D4S392 near the BAT-25 locus (p=0.035). In all 4 cases, non-cancerous DNA had two analogous peaks of BAT-26, indicating the heterozygosity of BAT-26 in constitutional DNA. This phenomenon was also detected in the peaks of BAT-25 in some cases, in whose constitutional DNAs, 1 bp size shift was also detectable in three other markers. To elucidate the reasons for the alterations of the 1 bp size shift of peak of these markers, we examined by microsatellite analysis mixed samples of tumour DNA with complete loss of the one allele at the 1p loci and each constitutional DNA sample of neuroblastoma patients. One base shift of the peak signal of the microsatellite marker was clearly obtained in proportion to the ratio of cancerous DNA and constitutional DNA. Fluorescent-based analysis of BAT-26 or BAT-25 was easy and useful for detection of MSI-H in colorectal cancers without analyzing non-cancerous DNA. A 1 bp size shift in BAT-26 or BAT-25 was considered to be affected by LOH at these loci. Thus, it is important to distinguish MSI from LOH to evaluated MSI using these markers.

Pancreatic metastasis of dermatofibrosarcoma protuberans.

Dermatofibrosarcoma protuberans (DFSP) is a relatively rare skin tumor that is considered to have intermediate malignancy; it demonstrates frequent local recurrence, but systemic metastasis is rare. We report a 49-year-old woman with pancreatic metastasis of DFSP who underwent total pancreatectomy with partial resection of the portal vein. Except for our patient, only two other cases of pancreatic metastasis of DFSP have been reported in the literature, to our knowledge. Radical resection may be considered for pancreatic metastasis of DFSP when there are no other metastatic lesions.

Adenosquamous carcinoma of the pancreas: preoperative diagnosis and molecular alterations.

Adenosquamous carcinoma of the pancreas is a rare tumor which has a less favorable prognosis than common ductal cell carcinoma of the pancreas, and a definite preoperative diagnosis of this tumor is quite difficult. We herein report two cases of this rare variant. The patients were a 41-year-old man (patient 1) and a 67-year-old woman (patient 2). Patient 1 had a hypoechoic mass measuring 3 cm in the uncus of the pancreas, while patient 2 had a huge mass, measuring 8 cm, in the tail of the pancreas. Patient 2 was successfully diagnosed preoperatively as having an adenosquamous carcinoma, by cytological examination of the pure pancreatic juice obtained by endoscopic retrograde pancreatic juice aspiration. A pylorus-preserving pancreatoduodenectomy was performed for patient 1, and a distal pancreatectomy with resection of the spleen and the left kidney was performed for patient 2. Subsequent pathological findings of these two tumors revealed adenosquamous carcinoma of the pancreas. K- ras point mutation, p53 overexpression, and telomerase activity in both tumor specimens were detected by the mutant allele specific amplification method, immunohistochemical staining, and telomeric repeat amplification protocol assay, respectively. The two patients died of recurrent disease 5 and 4 months, respectively, after surgery. Cytological examination of pure pancreatic juice is a useful modality for the preoperative diagnosis of this tumor, and frequent molecular alterations may be associated with the poor prognosis of adenosquamous carcinoma of the pancreas.

Pancreatic head resection with segmental duodenectomy for intraductal papillary mucinous tumors of the pancreas.

Various modifications of organ-preserving pancreatic resections have been performed for intraductal papillary mucinous tumor (IPMT) of the pancreas. The aim of this study was to evaluate usefulness of pancreatic head resection with duodenal segmentectomy (PHRSD), which is one of the organ-preserving pancreatic resections for IPMT. Pancreatic head resection with duodenal segmentectomy was indicated for the branch duct type of IPMT. Eight patients underwent PHRSD. The mean operative time was 390 minutes, and the mean blood loss was 1270 ml. Duodenal ischemia was prevented by preserving the duodenal branches of the gastroduodenal artery and the anterior inferior pancreaticoduodenal artery. Complications occurred in four patients: one with pancreatic leak, one with choledochoduodenal anastomotic stenosis, and two with delayed gastric emptying. However, no deaths occurred. The final pathologic diagnosis was adenoma in seven patients and carcinoma in situ in one patient. Six of eight patients had an adenoma with papillary growth in the main pancreatic duct. Postoperative pancreatic endocrine and exocrine functions were satisfactory. All patients were alive without recurrent disease at a median follow-up of 30 months. Pancreatic head resection with duodenal segmentectomy appears to be a useful procedure as an organ-preserving pancreatic resection for the branch duct type of IPMT, because this procedure allows a safe and complete resection of the pancreatic head without ischemia of the common bile duct and the duodenum.

Celiac axis occlusion with replaced common hepatic artery and pancreatoduodenectomy.

A rare case of intraductal papillary mucinous tumor of the pancreas associated with a replaced common hepatic artery and celiac axis occlusion, which was treated by pancreatoduodenectomy, is reported. In this patient, the celiac trunk was occluded at its root and the splenic and left gastric artery could be visualized serially via the enlarged collateral artery on superior mesenteric arteriography. At surgery, the collateral artery was carefully preserved and pancreatoduodenectomy was successfully performed without ischemia of the stomach, spleen, and remnant pancreas. Although celiac axis occlusion is an uncommon finding for patients undergoing pancreatoduodenectomy, we recommend performing celio-mesenteric angiography before pancreatoduodenectomy, and, at surgery, clamping of the gastroduodenal artery is required for patients with celiac axis occlusion.

Successful pre-operative diagnosis of malignant intraductal papillary mucinous tumor of the pancreas by detecting telomerase activity.

BACKGROUND: Pre-operative differential diagnosis between benign and malignant intraductal papillary mucinous tumor (IPMT) of the pancreas is markedly difficult by imaging examination. In recent years, telomerase activity has been reported to be detected only in malignant tumors. METHODS: A 52-yr-old man with abdominal pain was diagnosed with a IPMT through imaging examination. Telomerase activity of the pure pancreatic juice, which was obtained pre-operatively by endoscopic retrograde pancreatic juice aspiration (ERPJA), was analyzed by telomeric repeat amplification protocol (TRAP) assay. RESULTS: Telomerase activity was detected in the pure pancreatic juice of the patient, who was diagnosed with a malignant IPMT. A pylorus-preserving pancreatoduodenectomy was performed, and subsequent pathological findings revealed the tumor to be adenocarcinoma in adenoma with papillary growth. CONCLUSION: Detection of telomerase activity of the pure pancreatic juice might be useful to distinguish benign from malignant IPMT pre-operatively.

Successful diagnosis and resection of icteric type hepatocellular carcinoma.

We report a rare case of icteric type hepatocellular carcinoma with successful preoperative diagnosis and curative resection. A 50-year-old man was admitted to our hospital with fever elevation and jaundice. Endoscopic retrograde cholangiography revealed a tumor at the hepatic hilum, which caused obstruction of the right and left hepatic duct. The tumor was suspected of being a hilar cholangiocarcinoma, but it was diagnosed as being a hepatocellular carcinoma by endoscopic retrograde bile duct biopsy. After percutaneous transhepatic biliary drainage a right hemihepatectomy was performed. Subsequent pathological finding showed the tumor to be moderately-differentiated hepatocellular carcinoma (Edmondson III) which invaded into the right hepatic duct. The patient survived for three years without recurrence. Although patients with icteric type hepatocellular carcinoma have been reported to have a poor prognosis, earlier diagnosis and curative resection may occasionally bring them an improved prognosis.

[A case of recurrent gastric cancer with malignant ascites responding dramatically to chemotherapy with paclitaxel infused systemically and intraperitoneally].

We report a case in which chemotherapy with paclitaxel (TXL) infused systemically and intraperitoneally was effective for gastric cancer with malignant ascites. A 69-year-old man suffering from advanced gastric cancer with peritoneal dissemination underwent distal gastrectomy, a radical C operation. After chemotherapy with TS-1 and low-dose CDDP, TS-1 was administrated on an outpatient basis for 6 months. However, he complained of abdominal fullness and ascites, and received combination chemotherapy with paclitaxel infused systemically and intraperitoneally as second-line treatment. The ascites completely disappeared 5 weeks after administration. The only toxic event was anemia (grade 1), and no major adverse effects were observed.

[A case of advanced gastric cancer with abdominal paraaortic lymph node swelling successfully resected following neoadjuvant chemotherapy of TS-1 and low-dose cisplatin].

A 63-year-old man who had suffered from anorexia and body weight loss was admitted to the hospital. Upper GI series and an endoscopic examination revealed type 3 cancer in the posterior wall of the cardia. Abdominal CT scan showed enlargement of No. 16 lymph nodes. Preoperative diagnosis was stage IV gastric cancer (T3 (SE) H0 P0 N3), and we considered a curative operation impossible. Therefore, neoadjuvant chemotherapy with TS-1 and low-dose cisplatin (CDDP) was planned. After 4 weeks of administration, the primary lesion was reduced in size and the No. 16 lymph nodes were shrunken remarkably. Therefore, a total gastrectomy with a splenectomy, a distal pancreatectomy, and D3 lymph node dissection was performed. Histological findings demonstrated the degeneration of cancer cells and fibrosis in the primary tumor and metastatic regional lymph nodes. There were no viable cancer cells in the No. 16 lymph nodes. The histological changes against neoadjuvant chemotherapy were judged to be Grade 1b for the main tumor and Grade 3 for the No. 16 lymph nodes. Neoadjuvant chemotherapy with TS-1 and low-dose cisplatin is so effective in a short period that can be adapted to advanced gastric cancer for downstaging.

Usefulness of a 13C-labeled mixed triglyceride breath test for assessing pancreatic exocrine function after pancreatic surgery.

BACKGROUND: Although the fecal elastase-1 test is a satisfactory pancreatic exocrine function test, breath tests that use stable isotopes have been developed recently as alternatives. We evaluated the usefulness of a (13)C-labeled mixed triglyceride breath test for assessing pancreatic exocrine function after pancreatic surgery. METHODS: The breath test and the fecal elastase-1 test were performed on 7 healthy volunteers, 10 patients with chronic pancreatitis, and 95 patients after pancreatic surgery. The breath test was analyzed with isotope ratio mass spectrometry and the cumulative recovery of (13)CO(2) at 7 hours (% dose (13)C cum 7h) was calculated. The fecal elastase-1 concentration was determined immunoenzymatically. RESULTS: Both the fecal elastase-1 concentration and the % dose (13)C cum 7h of chronic pancreatitis patients and pancreatic resection patients were less than those of healthy volunteers. In all subjects, % dose (13)C cum 7h correlated with the fecal elastase-1 concentration (n = 112, R(2) = 0.14, P < .01). Accuracy rates for clinical symptoms, including clinical steatorrhea, for the fecal test and the breath test were 62 and 88%, respectively. CONCLUSION: The (13)C-labeled mixed triglyceride breath test might be more useful than the fecal elastase-1 test for evaluating pancreatic exocrine function after pancreatic resection.

Double intussusceptions in the small intestine caused by metastatic renal cell carcinoma: report of a case.

Renal cell carcinoma (RCC) may metastasize to almost any organ, but it is unlikely to be a direct cause of intussusception. We report a case of double enteric intussusceptions caused by metastatic RCC in a 64-year-old man. The patient presented with intermittent abdominal pain and diarrhea 11 years after undergoing a radical nephrectomy. Abdominal computed tomography (CT) showed two enhanced masses with the "target" sign, suggesting enteric intussusceptions. We performed partial enterectomy, and histological examination confirmed that the tumors had originated from RCC. To our knowledge, this is the first report of metastases from RCC manifesting as synchronous intraluminal polypoid tumors serving as the lead points of two intussusceptions in the small intestine. Thus, the possibility of multiple tumor metastases in the small intestine, with or without intussusceptions, should be considered in patients with recurrent RCC.