[A Case in Which Eating Ability Was Restored after Chemotherapy for Gastric Metastasis Following Colon Cancer Resection].

We report here a rare case of gastric metastasis after resection ofa transverse colon cancer in which eating ability was restored following mFOLFOX6 (folinic acid plus fluorouracil plus oxaliplatin) plus cetuximab (Cet) chemotherapy. A 56-year-old man with chief complaints of constipation and abdominal fullness was referred to our hospital. In February 2013, he was diagnosed with transverse colon cancer via enema and colonoscopy. We performed transverse colon cancer resection followed by a 6-month course of capecitabine chemotherapy. In July 2014, the patient's serum carcinoembryonic antigen level increased, in October, he was again referred to our hospital with complaints of appetite loss and vomiting. He was diagnosed with multiple lymph node and gastric metastases via ultrasonography, computed tomography, and endoscopy, as well as multiple lung metastases via computed tomography. As the gastric metastases and vomiting rendered him unable to eat, a nasogastric tube was inserted and was administered mFOLFOX6 plus Cet chemotherapy. After 2 courses of chemotherapy his ability to eat was restored. As of March 2015, the patient remains alive following 12 courses of chemotherapy.

[A case of long-term survival following chemotherapy after laparoscopic resection of sigmoid colon cancer with multiple liver metastases].

We report a rare case of long -term survival after laparoscopic resection of sigmoid colon cancer with multiple liver metastases, followed by 5-fluorouracil Leucovorin irinotecan with bevacizumab (FOLFIRI+Bev) chemotherapy. A 61-year-old woman was referred to our hospital with a principal complaint of bloody stools. She was diagnosed with sigmoid colon cancer by colonoscopy and multiple liver metastases by ultrasonography. In October 2008, we performed laparoscopic resection of the sigmoid colon cancer with multiple liver metastases, followed by 4 courses of modified 5-fluorouracil Leucovorin oxaliplatin ( mFOLFOX6) chemotherapy. In February 2009, abdominal ultrasonography showed progressive disease, and as a result the patient was administered 73 courses of FOLFIRI +Bev chemotherapy. As of March 2014, the patient has survived for more than 5 years following treatment, but still has liver metastases. The possibility of resecting multiple liver metastases from colorectal cancer should be considered, and in some cases, chemotherapy may enhance survival.

A phase II study of combined chemotherapy with 5-week cycles of S-1 and CPT-11 plus bevacizumab in patients with metastatic colon cancer.

OBJECTIVE: Combined chemotherapy with S-1 and irinotecan (IRIS) for metastatic colorectal cancer has been reported to be effective and safe. However, there are only a few studies on the effects of adding bevacizumab to IRIS. We conducted a clinical study to evaluate the efficacy and safety of IRIS plus bevacizumab as first-line therapy for metastatic colorectal cancer. METHODS: Forty metastatic colorectal cancer patients were enrolled in this phase II study. All patients received irinotecan (80 mg/m(2)) and bevacizumab (7 mg/kg) on days 1 and 15 and S-1 (40-60 mg twice daily) on days 1-21 of a 5-week repeated cycle. RESULTS: The response rate was 47.4% [95% confidence interval (CI) 31.5-63.2], progression-free survival was 11.9 months (95% CI 9.4-16.8), and overall survival was 23.4 months (95% CI 19.0-inf). The only grade 3 hematological toxicity was neutropenia (16%) and the incidences of grade 3 nonhematological toxicity were low at <10%, other than diarrhea (10.9%). CONCLUSION: In this clinical study, we revealed IRIS plus bevacizumab to be a promising first-line regimen for metastatic colorectal cancer with a low incidence of serious toxicities, in which favorable response rates and extension of survival time can be expected.

[Perioperative pain control and mortality].

Surgical stress response affects the neuroendocrine system and depresses the immune function. Anesthetic induction drugs (except propofol), volatile anesthetics and opioids also have an immunosupressive effect. Therefore, it is possible that the anesthetic drugs and methods may contribute to the recurrence of cancer after surgery. COX inhibitors prevent the opioid-induced tumor growth and metastasis, and regional anesthesia is expected to reduce the cancer recurrence via attenuating the surgical stress and reducing the amount of general anesthetics and opioids. Although some experimental studies and some clinical retrospective data show advantage of regional anesthesia over general anesthesia and opioid for postoperative analgesia, evidence level is still low and insufficient to prove its efficacy on postoperative mortality. Much more research and controlled clinical trials are needed to elucidate the advantage of the regional anesthesia in cancer operation.

[A patient with multiple liver metastases of gastric and rectal cancers after laparoscopic sigmoidectomy who responded completely to S-1 therapy followed by open gastrectomy].

We report a rare case of a patient with multiple liver metastases of gastric and rectal cancers after laparoscopic sigmoidectomy, who responded completely to S-1 therapy followed by open gastrectomy. A 72-year-old man with a chief complaint of occult blood in the feces was referred to our hospital and was diagnosed with rectal cancer by colonoscopy. In addition, we found concomitant gastric cancer by gastrointestinal fiberscopy. Abdominal plain computed tomography showed no liver metastasis. In August 2010, we performed laparoscopic resection of the rectal cancer. However, at the time of discharge, abdominal enhanced computed tomography showed multiple liver metastases. Then, we administered 4 courses of S-1 therapy. In December 2010, abdominal enhanced computed tomography showed no liver metastasis. In March 2011, because no other lesion without residual gastric cancer was detected, the patient underwent gastrectomy followed by S-1 therapy. As of January 2012, the patient is alive and disease free. S-1 therapy with laparoscopic resection for rectal cancer and gastrectomy may help prolong the survival of patients with multiple liver metastases of gastric and rectal cancers.

[A case of lung resection after chemotherapy due to lung metastases derived from esophageal cancer resection].

We report a rare case of esophageal cancer resection in which lung metastases was resected after chemotherapy with paclitaxel. A 59-year-old man with epigastralgia as a chief concern was referred to our hospital and was diagnosed with esophageal cancer by gastrointestinal fiber. In June 2007, the cancer was resected and followed by 3 courses of weekly chemotherapy with paclitaxel. In January 2009, chest computed tomography showed lung nodules (Rt-S1 and Rt-S5), and positron emission tomography (PET) showed uptake (Rt-S1); a final diagnosis of multiple lung metastases was made. Thereafter, the patient underwent 8 courses of weekly chemotherapy with paclitaxel. In December 2009, the growing Rt-S1 nodule was detected but no other lesion. The patient underwent a resection of lung metastases followed by 5 courses of weekly chemotherapy with paclitaxel. As of June 2011, the patient was alive and disease free. In conclusion, the resection of solitary lung metastases derived from esophageal cancer should be considered because it may improve survival.

Alcohols increase calmodulin affinity for Ca2+ and decrease target affinity for calmodulin.

It has been proposed that alcohols and anesthetics selectively inhibit proteins containing easily disrupted motifs, e.g., alpha-helices. In this study, the calcineurin/calmodulin/Ca(2+) enzyme system was used to examine the effects of alcohols on calmodulin, a protein with a predominantly alpha-helical structure. Calcineurin phosphatase activity and Ca(2+) binding were monitored as indicators of calmodulin function. Alcohols inhibited enzyme activity in a concentration-dependent manner, with two-, four- and five-carbon n-alcohols exhibiting similar leftward shifts in the inhibition curves for calmodulin-dependent and -independent activities; the former was slightly more sensitive than the latter. Ca(2+) binding was measured by flow dialysis as a direct measure of calmodulin function, whereas, with the addition of a binding domain peptide, measured calmodulin-target interactions. Ethanol increased the affinity of calmodulin for Ca(2+) in the presence and absence of the peptide, indicating that ethanol stabilizes the Ca(2+) bound form of calmodulin. An increase in Ca(2+) affinity was detected in a calmodulin binding assay, but the affinity of calmodulin for calcineurin decreased at saturating Ca(2+). These data demonstrate that although specific regions within proteins may be more sensitive to alcohols and anesthetics, the presence of alpha-helices is unlikely to be a reliable indicator of alcohol or anesthetic potency.

[A case of severe acute hyperkalemia during pre-anhepatic stage in living-related liver transplantation].

We reported a case of severe acute hyperkalemia during pre-anhepatic stage in living-related liver transplantation. The serum potassium concentration was elevated from 5.1 mmol.l-1 to 7.3 mmol.l-1 after hepatic artery ligation. Inspite of administration of diuretics, calcium and glucose-insulin, T wave on ECG was elevated and premature ventricular contractions occurred frequently. Finally, ventricular tachycardia occurred three times. After hepatic vein ligation, in anhepatic stage, serum potassium decreased gradually to 3.7 mmol.l-1 and arrhythmia disappeared. We consider that the main cause of hyperkalemia in this case is flowing out of potassium from the ischemic liver by surgical manipulation. It is necessary to take care of the change of serum potassium concentration not only in postreperfusion but also pre-anhepatic stage in living-related liver transplantation.

[Two cases of non-MICS surgery successfully managed with Port-Access EndoCPB system].

We report two cases of non-MICS surgery successfully managed with Port-Access EndoCPB system. The first patient is a case of non-ruptured giant aneurysm of middle cerebral artery proposed for clipping procedure under hypothermic cardiopulmonary arrest. The second patient is a case of infectious pseudoaneurysm of the ascending aorta. We conclude that this system can be a powerful option of anesthetic strategy for the patients in need of cardiac arrest without having severe physical stress like sternotomy.

[Living-related liver transplantation in a patient with hepatopulmonary syndrome].

We experienced the perioperative management of the living related liver transplantation (LRLT) in a patient with hepatopulmonary syndrome (HPS). HPS is seen in 15% of patients of the endstage liver failure, and it accompanies the various types of hypoxia. The diagnostic standards of HPS are chronic liver disease usually complicated by portal hypertension with or without cirrhosis, arterial hypoxemia (PaO2 < 70 mmHg or A-aDO2 gradient > 20 mmHg), and intrapulmonary vascular dilation. The present case conformed to the diagnostic standard. But this case was of a mild type of HPS, because PaO2 was elevated after O2 inhalation and extrapulmonary uptake of 99mTcMAA after lung perfusion was lower than 40%. During perioperative period of LRLT, there were no complications such as hypoxia, acute rejection, bleeding and infection. Therefore HPS would be improved after LRLT. In the management of perioperative period it is important to be aware of hypoxia and to evaluate preoperatively the condition of the patient properly.

[Severe acute pulmonary edema during living related liver transplantation surgery].

We report a case of severe intraoperative pulmonary edema during living related liver transplantation (LRLT) surgery. A 60-year-old woman with end-stage primary biliary cirrhosis underwent LRLT. After administration of several units of packed red blood cells and fresh frozen plasma, a gradual decline in oxygen saturation was observed. After an unexpectedly prolonged ahepatic phase, she developed severe pulmonary edema and critical hypoxemia. Further deterioration of hypoxemia was observed after reperfuion of the portal vein. We conclude that this severe pulmonary edema was caused by transfusion related acute lung injury, and prolonged ahepatic phase with reperfusion injury deteriorated the lung condition.

[Changes of urinary tripsin inhibitor in blood and urine, as well as serum cytokines in living related liver transplantation].

BACKGROUND: Living related liver transplantation induces the production of many inflammatory and anti-inflammatory cytokines. Urinary tripsin inhibitor (UTI) is produced in the liver and wellknown as one of the markers of surgical stress. METHODS: To clarify the significance of UTI in blood and urine and serum cytokines in living related liver transplantation, we examined the changes of UTI, polymorphonuclear elastase (PMNE), interleukin (IL)-6, IL-1 ra and IL-10 perioperatively. RESULTS: UTI in blood increased gradually after operation. It increased from 5.2 +/- 2.2 U.ml-1 at the end of operation to 19.4 +/- 7.5 U.ml-1 on the 10 th postoperative day (POD). Similarly, UTI in urine increased after operation and the peak was on the 7th POD. Cytokines including IL-6, IL-1 ra and IL-10 showed similar changes in general gastrointestinal surgery, but the peak values in liver transplantation were lower. CONCLUSION: These results demonstrate that the recovery of the transplanted liver function require certain time after operation and UTI in urine could be an important marker whether the liver is working or not. The immunosuppressive drugs, like steroid, administered during and after operation would suppress the production of cytokines.