The oral disposition index calculated from a meal tolerance test is a crucial indicator for evaluating differential normalization of postprandial glucose and triglyceride excursions in morbidly obese patients after laparoscopic sleeve gastrectomy.

To determine the normalization of postprandial blood glucose (PG) and triglyceride (TG) excursions in 30 morbidly obese patients with or without diabetes mellitus (DM) 1-year after they underwent a laparoscopic sleeve gastrectomy (LSG) vs. their pre-surgery data, we administered the 75-g oral glucose tolerance test (OGTT) and a meal tolerance test (MTT) using a 75-g glucose-equivalent carbohydrate- and fat-containing meal. The results were as follows; (i) Postoperative body-weight reduction was associated with DM remission and reduced multiple cardiometabolic risks. (ii) OGTT data showing postprandial hyper-insulinemic hypoglycemia in many post-surgery patients were associated with overdiagnosis of improved glucose tolerance. However, postoperative MTT data without hypoglycemia showed no improvement in the glucose tolerance vs. pre-surgery data. (iii) The disposition index (DI) i.e., [Matsuda index] × (Glucose-induced insulin secretion) was progressively worsened from normal glucose tolerance to DM patients after LSG. These post-surgery DI values measured by the MTT were correlated with 2h-plasma glucose levels and were not normalized in DM patients. (iv) The baseline, 2h-TG, and an increase in 2h-TG values above baseline were correlated with the insulin resistance index, DI, or HbA1c; These TG values were normalized post-LSG. In conclusion, the glucose tolerance curve measured by the MTT was not normalized in T2DM patients, which was associated with impaired normalization of the DI values in those patients 1-year after the LSG. However, the baseline TG and a fat-induced 2h-TG values were normalized postoperatively. The MTT can be used to assess normalization in postprandial glucose and TG excursions after LSG.

Effects of a new 75 g glucose- and high fat-containing cookie meal test on postprandial glucose and triglyceride excursions in morbidly obese patients.

A new meal tolerance test (MTT) using a 75 g glucose- and high fat-containing meal was applied to classify glucose intolerance in morbidly obese patients. According to the MTT data, the concordance rate of diagnosis was 82.5% compared to the 75 g oral glucose tolerance test (OGTT) in patients with normal glucose tolerance (NGT, n = 40). In the NGT patients, the insulinogenic index (r = 0.833), Matsuda index (r = 0.752), and disposition index (r = 0.845) calculated from the MTT data were each significantly (p < 0.001) correlated with those derived from the OGTT data. However, in patients with impaired glucose tolerance (IGT, n = 23) or diabetes mellitus (DM, n = 17), the postprandial glucose levels post-MTT were significantly lower than those post-OGTT, without increases in the postprandial insulin levels post-MTT. Thus, the severity of glucose intolerance measured by the MTT was milder than that indicated by the OGTT. Plasma levels of both glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP) were increased at the postprandial state, but only the GIP levels post-MTT were significantly higher than those post-OGTT. The enhancement of glucose disposal rates in patients with NGT or IGT after the MTT was associated with increased GIP levels. The postprandial hypertriglyceridemia induced by the MTT was associated with insulin resistance, but it was not associated with the impaired insulinogenic index or the disposition index. These results indicate that the new MTT is clinically useful to evaluate both abnormal glucose and triglyceride excursions caused by abnormal insulin sensitivity and secretions of insulin and gut hormones in morbidly obese patients.

[A case of gastric adenosquamous carcinoma with peritoneal dissemination in which treatment with S-1 plus paclitaxel therapy resulted in improved long-term survival].

Gastric adenosquamous carcinoma is a rare malignancy with a poor prognosis. We recently performed palliative gastrectomy for a gastric adenosquamous carcinoma with peritoneal dissemination and provided a course of systemic chemotherapy with S-1 plus paclitaxel(PTX)after the surgery. No serious adverse events were observed, and treatment with S-1 plus PTX was continued for 1 year before being switched to adjuvant chemotherapy with S-1 alone for another year. The tumor maker levels normalized within 2 months of the initial treatment, and the peritoneal dissemination could no longer be detected by abdominal computed tomography(CT). The patient remained in clinical remission and maintained long-term survival of over 8 years.

Cytoreductive surgery for synchronous and metachronous colorectal peritoneal dissemination: Japanese P classification and peritoneal cancer index.

Aim: The outcomes of cytoreductive surgery (CRS) for synchronous and metachronous colorectal peritoneal dissemination were investigated using the Japanese P classification and peritoneal cancer index (PCI). Methods: CRS was performed in 111 cases of synchronous peritoneal dissemination and 115 cases of metachronous peritoneal dissemination. The P classification and PCI were determined at the time of laparotomy. Results: In the synchronous dissemination group, the 5-year overall survival rates after CRS in P1/P2 and P3 cases were 51% and 13%, respectively. Even for P3, 51% of the patients achieved macroscopic cytoreductive complete resection (CC-0), with a 5-year survival rate of 40%. When P3 cases were classified into PCI 0-9, 10-19, 20-29, and 30-39, CC-0 was achieved in 93%, 70%, 6%, and 0% of the cases, respectively, and the 5-year survival rate of PCI 0-9 was 41%. In the metachronous dissemination group, the 5-year survival rates were 62% for PCI 0-9 and 22% for PCI 10-19; 5-year survival was not observed in patients with a PCI ≥ 20. CC-0 was significantly associated with the postoperative prognosis in both synchronous and metachronous peritoneal dissemination. Conclusion: In cases of synchronous dissemination, CRS must be performed for P1 and P2 cases or those with a PCI < 10, while detailed examination using PCI is required for P3 cases. In cases of metachronous dissemination, CRS should be considered when the PCI score is <20.

A unique case of high-grade myofibroblastic sarcoma initially presenting with oral symptoms.

High-grade myofibroblastic sarcoma is a rare mesenchymal tumor with a high recurrence and metastatic rate. Few cases of high-grade myofibroblastic sarcomas have been reported. Herein, we report a rare case of undifferentiated, high-grade myofibroblastic sarcoma with an unclear primary site, initially presenting with oral symptoms. High-grade myofibroblastic sarcoma was diagnosed following an excisional biopsy of a gingival tumor. After this excisional biopsy, systemic imaging revealed multiple metastases in the tonsil, lung, liver, kidney, and eye. The patient underwent two cycles of chemotherapy (doxorubicin). During follow-up, the tumor progressed rapidly and metastasized to the skin of the head and neck. The patient expired three months after the initial examination.

A rare case of pseudomyxoma peritonei with Morgagni hernia.

Both pseudomyxoma peritonei and Morgagni hernias in adults are rare clinical conditions. A 70-year-old woman who was diagnosed with pseudomyxoma peritonei with Morgagni hernia underwent cytoreductive surgery and primary repair. Pseudomyxoma peritonei causes increased intra-abdominal pressure that may lead to acquired congenital diaphragmatic hernia when there is a local fragility in the diaphragmatic musculature. Parietal peritonectomy of the right diaphragmatic peritoneum can safely remove the hernia sac. The high rate of infections associated with cytoreductive surgery causes hesitation for concurrent mesh repair for Morgagni hernia. This is the first report of pseudomyxoma peritonei with Morgagni hernia. Cytoreductive surgery including parietal peritonectomy of the right diaphragmatic peritoneum plus primary repair of hernial defect was performed safely and successfully, which achieved positive short-term results for patients with pseudomyxoma peritonei-associated Morgagni hernia.

A newly developed glucagon sandwich ELISA is useful for more accurate glucagon evaluation than the currently used sandwich ELISA in subjects with elevated plasma proglucagon-derived peptide levels.

AIMS/INTRODUCTION: Glucagon, a peptide hormone produced from proglucagon, is involved in the pathophysiology of diabetes. Plasma glucagon levels are currently measured by sandwich enzyme-linked immunosorbent assay (ELISA), but the currently used sandwich ELISA cross-reacts with proglucagon-derived peptides, thereby providing incorrect results in subjects with elevated plasma proglucagon-derived peptide levels. We aimed to develop a more broadly reliable ELISA for measuring plasma glucagon levels. MATERIALS AND METHODS: A new sandwich ELISA was developed using newly generated monoclonal antibodies against glucagon. After its validation, plasma glucagon levels were measured with the new ELISA and the currently used ELISA in subjects who underwent laparoscopic sleeve gastrectomy (LSG) and in outpatients with suspected glucose intolerance. The ELISA results were compared with those from liquid chromatography-high resolution mass (LC-HRMS) analysis, which we previously established as the most accurate measuring system. RESULTS: The new ELISA has high specificity (<1% cross-reactivities) and high sensitivity (a lower range of 0.31 pmol/L). Plasma glucagon values in the subjects who underwent laparoscopic sleeve gastrectomy and some outpatients with suspected glucose intolerance differed between the new ELISA and the currently used ELISA. These subjects also showed markedly high plasma glicentin levels. Despite the elevated plasma glicentin levels, the new ELISA showed better positive correlation with LC-HRMS than did the currently used ELISA. CONCLUSIONS: The new ELISA enables more accurate measurement of plasma glucagon than the currently used ELISA, even in subjects with elevated proglucagon-derived peptide levels. It should be clinically useful in elucidating the pathophysiology of individual diabetic patients.

Implantation of sigmoid colon cancer into the endoscopic resection site of intramucosal rectal cancer: A case report.

A 70-year-old woman was diagnosed with intramucosal rectal cancer and advanced sigmoid colon cancer at the same time. First, the intramucosal rectal cancer was curatively resected by endoscopic submucosal dissection, and surgery was subsequently performed for sigmoid colon cancer. After 20 months, a follow-up colonoscopy revealed a tumor growth at the ulcer scar of the endoscopic submucosal dissection. Histological findings and KRAS mutation analysis suggested implantation of sigmoid colon cancer to the post-endoscopic submucosal dissection site of intramucosal rectal cancer.

Sequential interaction of phenytoin and phenobarbital with fluorouracil.

OBJECTIVE: We report a case of sequential interaction of phenytoin (PHT) and phenobarbital (PB) with fluorouracil (5-FU). CASE REPORT: A male patient aged 60 under treatment with PHT and PB in which serum concentrations of PHT (32.8 µg/ml) and PB (26.7 µg/ml) increased ~ 2-fold after the start of postoperative adjuvant therapy with calcium levofolinate (l-LV) and fluorouracil (5-FU). When the drug interactions of this case evaluated using the Drug Interaction Probability Scale, was assessed as "probable". DISCUSSION: In this case, 5-FU increased PHT, which in turn may have increased the PB concentration, suggesting that when fluoropyrimidine antitumor agents are administered to patients receiving PHT in combination with other drugs, some measures should be taken in consideration of secondary effects of antitumor agents on other drugs that may possibly interact with PHT, including frequent monitoring of blood drug concentration.

A desmoid-type fibromatosis in the retroperitoneum of the gastro-pancreatic region that was resected with a distal pancreatomy: a case report.

An 80-year-old man was referred to our hospital because of epigastric pain. Abdominal computed tomography revealed a well-defined circular intra-abdominal mass in the gastro-pancreatic region measuring 15 mm in diameter. After 6 months, the mass lesion was growing with mild enhancement, and weaker enhancement was found in the lower half of the mass on contrast-enhanced computed tomography. The mass lesion touched the stomach, whereas adipose tissue appeared to intervene between the mass and pancreas. On magnetic resonance imaging, the well-defined mass lesion had isointensity to muscle on T1-weighted imaging, slight hyperintensity to muscle on T2-weighted imaging, which indicated a rich fibrous tumor. Under general anesthesia, the patient underwent open surgery. Intraoperatively, the tumor was separated from the stomach and firmly attached to the pancreas. Therefore, we performed a distal pancreatomy with splenic resection. Pathological diagnosis was desmoid-type fibromatosis in the retroperitoneum, and the tumor margin was attached to the pancreas, splenic artery, and splenic vein. Since there are few reports of desmoid-type fibromatosis occurring in the retroperitoneum of the gastropancreatic region, it is difficult to distinguish from other soft tissue tumors and to identify the tumor origin. Close observation by radiological re-valuation was a useful option. Magnetic resonance imaging signals and an enhanced pattern may help distinguish a desmoid-type fibromatosis from other soft tissue tumors. A desmoid-type fibromatosis that is well-defined in radiological findings may infiltrate the surrounding organs with gross or pathological analyses.

Perioperative physical and nutritional therapy for tongue cancer-induced malnutrition and muscle atrophy: A case report.

Malnutrition is a common complication in patients with tongue cancer who experience dysphagia and can steadily lead to skeletal muscle atrophy. Additionally, skeletal muscle loss commonly occurs in patients after invasive surgery. Therefore, patients with tongue cancer are at high risk of skeletal muscle atrophy during the perioperative phase of treatment. Over time, physical and nutritional therapy are expected to increase skeletal muscle mass and improve nutritional status. However, immediate benefits for patients in the perioperative phase of treatment are largely unknown. This case report aimed to evaluate the combined effects of physical and nutritional therapy for a patient in the perioperative phase of treatment for tongue cancer. We describe a 48-year-old woman diagnosed with tongue cancer. Her increasing difficulty with eating and swallowing led to malnutrition. After hospital admission for oral surgery, physical and nutritional therapy were initiated. Skeletal muscle mass measured by body composition analyzer and ultrasound apparatus showed increases, whereas blood tests to indicate nutritional status showed no improvement. This case suggests that physical and nutritional therapy are effective for increasing skeletal muscle during perioperative phase treatment in malnourished patients with tongue cancer and assessment of skeletal muscle mass is a reliable method for clinical evaluation.

Long-Term Outcomes of Bariatric and Metabolic Surgery in Japan: Results of a Multi-Institutional Survey.

BACKGROUND: The number of bariatric procedures performed in Japan is increasing. There are isolated reports of bariatric surgery, but there have been no nationwide surveys including long-term data. METHODS: We retrospectively reviewed data for patients who underwent bariatric and metabolic surgery throughout Japan and reviewed outcomes. Surveys were sent to ten institutions for number of procedures, preoperative patient weight and preoperative obesity-related comorbidities, and data at 1, 3, and 5 years postoperatively. Improvement of type 2 diabetes mellitus at 3 years after surgery was stratified by baseline ABCD score, based on age, body mass index, C-peptide level, and duration of diabetes. RESULTS: Replies were received from nine of the ten institutions. From August 2005 to June 2015, 831 patients, including 366 males and 465 females, underwent bariatric procedures. The mean age was 41 years, and mean BMI was 42 kg/m2. The most common procedure was laparoscopic sleeve gastrectomy (n = 501, 60 %) followed by laparoscopic sleeve gastrectomy with duodenojejunal bypass (n = 149, 18 %). Laparoscopic Roux-en-Y gastric bypass was performed in 100 patients (12 %), and laparoscopic adjustable gastric banding was performed in 81 (10 %). At 3 years postoperatively, the remission rate of obesity-related comorbidities was 78 % for diabetes, 60 % for hypertension, and 65 % for dyslipidemia. Patients with complete remission of diabetes at 3 years postoperatively had a higher ABCD score than those without (6.4 ± 1.6 vs 4.2 ± 2.0, P < 0.05). CONCLUSIONS: Bariatric and metabolic surgery for Japanese morbidly obese patients is safe and effective. These results are comparable with the results of previous studies.

[Fundamental studies on locally injected methotrexate bound to activated carbon particles (MTX-CH)].

We developed a new dosage formulation of methotrexate bound to activated carbon particles (MTX-CH). In this study, subcutaneous injection of MTX-CH was examined for its long-acting effect at the injection sites, anti-tumor effect and acute toxicity in mice. MTX-CH- or MTX aqueous solution (MTX-SOL)- was injected locally into tumors growing on the back of BALB/c mice at a dosage of 30 mg/kg as methotrexate (MTX). (1) The MTX concentration at the injection sites remained higher in mice with MTX-CH than that with MTX-SOL. (2) A marked effect on the control of tumor growth by MTX-CH was noted after repeated injections throughout the observation period. These results suggest that MTX-CH is superior to MTX-SOL due to longer-acting effects at the administration site and have a better control of tumor growth than MTX aqueous solution (MTX-SOL).

Primary intestinal follicular lymphoma and premature atherosclerosis in a Japanese diabetic patient with atypical familial partial lipodystrophy.

We experienced a case of primary intestinal follicular lymphoma and premature atherosclerosis in a diabetic patient with familial partial lipodystrophy (FPL) that was detected when the patient was evaluated for laparoscopic sleeve gastrectomy (LSG). As FPL is generally considered to be rare, FPL is often underdiagnosed, especially in obese patients. Therefore, the prevalence of FPL is higher than previous estimates. Our case illustrates that clinicians should perform screening for atherosclerosis and malignancy at the preoperative evaluation and may need to perform metabolic surgery earlier to prevent the development of excess truncal fat, complicated diabetes and atherosclerosis in patients with FPL.