[A case of advanced gastric cancer with para-aortic lymph node metastases responding to S-1/CDDP chemotherapy that leads to a pathological complete response].

A 66-year-old man complaining of epigastralgia was referred to our hospital. We examined the patient and diagnosed advanced gastric cancer (ML, type 3, por, cT3, cN3, cH0, cP0, cM1[LYM], cStage IV). A poor outcome was predicted, so we attempted induction chemotherapy and expected tumor downstaging. We chose S-1/CDDP therapy. S-1 was administered orally for 21 days, followed by CDDP div on day 8. Total gastrectomy and lymph node dissection (D2+No. 12a, No. 13,16) was performed using Roux-en-Y reconstruction. Histological examination of the resected stomach and lymph nodes revealed no residual cancer cells, suggesting complete histological remission (grade 3) according to the Japanese classification of gastric carcinoma. The patient has been in good health without recurrence for 12 months after surgery.

A flexible-arm liver retractor that provides an optimal surgical field without postoperative liver dysfunction.

BACKGROUND/AIMS: It is important to retract the lateral liver segment during laparoscopic gastrectomy to achieve an optimal surgical field. Few retractors cause transient liver dysfunction after surgery; therefore, for an easier and safer procedure, we devised a new liver retractor and implemented a trial clinical application. METHODOLOGY: The novel liver retractor comprises a metallic, flexible arm retractor attached to the operating table and an air compressor which pneumatically moves and fixes the retractor. It was inserted directly into the abdominal cavity just below the xiphisternum to retract the left lobe of the liver anterosuperiorly, thereby exposing the hiatus. Blood samples were collected from the patients on days 1, 3, and 7 after surgery to assess the levels of the liver enzymes AST and ALT. RESULTS: During laparoscopic gastrectomy, no liver damage was observed macroscopically. The surgical fields obtained were optimal and efficient for laparoscopic surgery. Notably, it was possible to retract the liver as often as needed. Further, none of the patients developed postoperative liver dysfunction. CONCLUSIONS: The novel flexible-arm retractor provided an optimal surgical field without inducing liver dysfunction.

Pore-scale modeling of two-phase flow: A comparison of the generalized network model to direct numerical simulation.

Despite recent advances in pore-scale modeling of two-phase flow through porous media, the relative strengths and limitations of various modeling approaches have been largely unexplored. In this work, two-phase flow simulations from the generalized network model (GNM) [Phys. Rev. E 96, 013312 (2017)2470-004510.1103/PhysRevE.96.013312; Phys. Rev. E 97, 023308 (2018)2470-004510.1103/PhysRevE.97.023308] are compared with a recently developed lattice-Boltzmann model (LBM) [Adv. Water Resour. 116, 56 (2018)0309-170810.1016/j.advwatres.2018.03.014; J. Colloid Interface Sci. 576, 486 (2020)0021-979710.1016/j.jcis.2020.03.074] for drainage and waterflooding in two samples-a synthetic beadpack and a micro-CT imaged Bentheimer sandstone-under water-wet, mixed-wet, and oil-wet conditions. Macroscopic capillary pressure analysis reveals good agreement between the two models, and with experiments, at intermediate saturations but shows large discrepancy at the end-points. At a resolution of 10 grid blocks per average throat, the LBM is unable to capture the effect of layer flow which manifests as abnormally large initial water and residual oil saturations. Critically, pore-by-pore analysis shows that the absence of layer flow limits displacement to invasion-percolation in mixed-wet systems. The GNM is able to capture the effect of layers, and exhibits predictions closer to experimental observations in water and mixed-wet Bentheimer sandstones. Overall, a workflow for the comparison of pore-network models with direct numerical simulation of multiphase flow is presented. The GNM is shown to be an attractive option for cost and time-effective predictions of two-phase flow, and the importance of small-scale flow features in the accurate representation of pore-scale physics is highlighted.

Surgical advantages of gastric SMTs by laparoscopy and endoscopy cooperative surgery.

BACKGROUND/AIMS: The treatment of gastric submucosal tumors (SMTs) is strictly surgical and enucleation of the tumor or wedge resection of the stomach is efficient to achieve R0 resection. Laparoscopic and endoscopic cooperative surgery (LECS) can be safely performed with adequate cutting lines. This study describes the initial 16 cases treated by LECS and evaluates the advantages by LECS for gastric SMTs retrospectively. METHODOLOGY: Sixteen patients with gastric SMT underwent LECS from June 2007 to December 2010, their surgical data, clinical characteristics and surgical specimens of SMTs were compared. The surgical specimens of 9 gastric SMTs treated by laparoscopic wedge resection (LWR) were compared as a control. RESULTS: The median (range) length of operation time, blood loss, hospital stay after surgery were minutes 172 (115- 220), <5mL (<5-115) and 10 days (6-17), respectively. The median (range) ratio of the longest diameter of the tumor divided by the longest diameter of the surgical specimen in LECS and LWR were 0.86 (0.625-1.0) and 0.69 (0.44-1.0), respectively (p=0.0189, Wilcoxon rank sum test). CONCLUSIONS: LECS minimizes the surgical specimen while still providing sufficient surgical margins to successfully cure gastric SMTs.

The classification of anatomic variations in the perigastric vessels by dual-phase CT to reduce intraoperative bleeding during laparoscopic gastrectomy.

BACKGROUND: Laparoscopy-assisted distal gastrectomy (LADG) is a less invasive alternative compared with an open procedure. However, it is difficult to obtain a full-view image and to estimate the three-dimensional (3D) relationships between organs during laparoscopic procedures. Determining the vascular anatomy by 3D CT imaging has been shown to play a critical role in reducing the risks associated with laparoscopic gastric cancer surgery. The purpose of this study was to evaluate the clinical anatomic variations and to estimate its positive contribution in obtaining less intraoperative bleeding. METHODS: Scanning was performed using a 64-row MDCT scanner. Three-dimensional CT images in the arterial and portal phase were reconstructed and fused together using the volume-rendering technique. The intraoperative bleeding findings were compared between two periods. RESULTS: The anatomic variations of the celiac trunk were divided into six types. There were 159 patients with Adachi's type I, type II=8, type III=1, type IV=1, type V=2, type VI=3, and other=1. The inflows of the left gastric coronary vein (LCV) were divided into three types. The LCV flowed into the portal vein (PV) in 79 patients, into the splenic vein (SpV) in 65, and into the junction of these two veins in 27. The splenic artery was divided into flat type and curved type, and 65 cases (37%) showed the flat type. Intraoperative bleeding was significantly less between 2007 and 2008, in which the operations were performed without first making a 3D anatomy study, than in 2009, in which 3D anatomy studies were made and analyzed before surgery in all patients. CONCLUSIONS: Dual-phase 3D CT is a useful and essential modality to visualize the precise anatomy around the stomach. As a result, by comparing 3D CT images with our classifications, it is believed that any surgeons may reduce the degree of intraoperative blood loss.

Low peritoneal and systemic inflammatory response after laparoscopy-assisted gastrectomy compared to open gastrectomy.

BACKGROUND/AIMS: Peritoneal immune response as well as systemic response was objectively evaluated in laparoscopy-assisted distal gastrectomy (LADG) compared to open distal gastrectomy (ODG). METHODOLOGY: A total of 42 patients with gastric cancer were enrolled, with 23 undergoing LADG and 19 ODG. We evaluated the levels of IL-6 in peritoneal drain fluid, serum C-reactive protein (CRP), white blood cells (WBC), and the postoperative presence of systemic inflammatory response syndrome (SIRS). RESULTS: The serum CRP level was significantly higher in the ODG group than in the LADG group (p=0.007) on postoperative day (POD) 1. WBC counts showed no statistically significant difference between the two groups (p=0.105). The rate of cases exhibiting SIRS was significantly higher in the ODG group than in the LADG group (p<0.001). The IL-6 level of drain fluid was significantly higher in the ODG group than the LADG group (p<0.01) on POD1. Although weak correlation between IL-6 on POD1 and blood loss (R=0.38, p=0.0154) was observed, no significant correlation between IL-6 and operation time was noted. CONCLUSIONS: LADG seems to be a lesser traumatic approach for the treatment of gastric cancer.

Survival predictors of patients with primary duodenal adenocarcinoma.

This single-institution experience retrospectively reviewed the outcomes in 21 patients with primary duodenal adenocarcinoma. Twelve patients underwent curative surgery, and 9 patients underwent palliative surgery at the Chiba University Hospital. The maximum follow-up period was 8650 days. All pathologic specimens from endoscopic biopsy and surgical specimens were reviewed and categorized. Twelve (57.1%) patients underwent curative surgery (R0): 4 pancreaticoduodenectomies (PD), 4 pylorus-preserving PDs (PpPD), 2 local resections of the duodenum and 2 endoscopic mucosal resections (EMR). Palliative surgery was performed for 9 patients (42.9%) following gastro-intestinal bypass. The median cause-specific survival times were 1784 days (range 160-8650 days) in the curative surgery group and 261 days (range 27-857 days) in the palliative surgery group (P = 0.0003, log-rank test). The resectability of primary duodenal adenocarcinoma was associated with a smaller tumor size, a lower degree of tumor depth invasiveness, and less spread to the lymph nodes and distant organs.

Salivary amylase activity is useful for assessing perioperative stress in response to pain in patients undergoing endoscopic submucosal dissection of gastric tumors under deep sedation.

BACKGROUND: Although endoscopic submucosal dissection (ESD) for patients with gastric tumors under the conditions of unconsciousness is considered to be minimally invasive, no objective assessment of the perioperative stress of ESD has yet been conducted. Today, stress levels can be easily and objectively assessed by monitoring salivary amylase activity (sAMY). We evaluated the perioperative changes in the sAMY in patients undergoing ESD and identified the causes of such changes. METHODS: A total of 40 patients with gastric cancers/adenomas removed by ESD under general anesthesia (GA; n = 20) and under deep sedation (DS; n = 20) were enrolled. sAMY was measured using the enzyme analysis equipment, sAMY Monitor (NIPRO, Osaka, Japan) during the perioperative period of the ESD. Also, all patients were interviewed to determine their subjective stress level, using a questionnaire asking "How did you feel during ESD?", with the choice of responses ranging from "did not wake up at all" to "I was awake and ESD was extremely stressful". RESULTS: The sAMY of the DS group increased soon after the start of ESD. Meanwhile, that of the GA group decreased just after the ESD started and was maintained at a stable level throughout the ESD. In response to the stress level questionnaire, all of the patients in the GA group and a majority of the patients in the DS group responded, "did not wake up at all". CONCLUSION: Sympathetic agitation, expressed as an increase of sAMY, was absent in the GA group. Meanwhile, in the DS group, some patients showed high levels of sAMY which went down following the administration of an analgesic agent, thus suggesting that pain caused an elevation in the level of the stress and thereby induced an increase in sAMY. The measurement of sAMY is therefore considered to be useful for the assessment of analgesic status under DS.

Pore-scale numerical simulation of low salinity water flooding using the lattice Boltzmann method.

HYPOTHESIS: The change of wettability toward more water-wet by the injection of low salinity water can improve oil recovery from porous rocks, which is known as low salinity water flooding. To simulate this process at the pore-scale, we propose that the alteration in surface wettability mediated by thin water films which are below the resolution of simulation grid blocks has to be considered, as observed in experiments. This is modeled by a wettability alteration model based on rate-limited adsorption of ions onto the rock surface. SIMULATIONS: The wettability alteration model is developed and incorporated into a lattice Boltzmann simulator which solves both the Navier-Stokes equation for oil/water two-phase flow and the advection-diffusion equation for ion transport. The model is validated against two experiments in the literature, then applied to 3D micro-CT images of a rock. FINDINGS: Our model correctly simulated the experimental observations caused by the slow wettability alteration driven by the development of water films. In the simulations on the 3D rock pore structure, a distinct difference in the mixing of high and low salinity water is observed between secondary and tertiary low salinity flooding, resulting in different oil recoveries.

Evaluation of methods using topology and integral geometry to assess wettability.

HYPOTHESIS: The development of high-resolution in situ imaging has allowed contact angles to be measured directly inside porous materials. We evaluate the use of concepts in integral geometry to determine contact angle. Specifically, we test the hypothesis that it is possible to determine an average contact angle from measurements of the Gaussian curvature of the fluid/fluid meniscus using the Gauss-Bonnet theorem. THEORY AND SIMULATION: We show that it is not possible to unambiguously determine an average contact angle from the Gauss-Bonnet theorem. We instead present an approximate relationship: 2πn(1-cosθ)=4π-∫κG12dS12, where n is the number of closed loops of the three-phase contact line where phases 1 and 2 contact the surface, θ is the average contact angle, while κG12 is the Gaussian curvature of the fluid meniscus which is integrated over its surface S12. We then use the results of pore-scale lattice Boltzmann simulations to assess the accuracy of this approach to determine a representative contact angle for two-phase flow in porous media. FINDINGS: We show that in simple cases with a flat solid surface, the approximate expression works well. When applied to simulations on pore space images, the equation provides a robust estimate of contact angle, accurate to within 3°, when averaged over many fluid clusters, although individual values can have significant errors because of the approximations used in the calculation.

Using energy balance to determine pore-scale wettability.

HYPOTHESIS: Based on energy balance during two-phase displacement in porous media, it has recently been shown that a thermodynamically consistent contact angle can be determined from micro-tomography images. However, the impact of viscous dissipation on the energy balance has not been fully understood. Furthermore, it is of great importance to determine the spatial distribution of wettability. We use direct numerical simulation to validate the determination of the thermodynamic contact angle both in an entire domain and on a pore-by-pore basis. SIMULATIONS: Two-phase direct numerical simulations are performed on complex 3D porous media with three wettability states: uniformly water-wet, uniformly oil-wet, and non-uniform mixed-wet. Using the simulated fluid configurations, the thermodynamic contact angle is computed, then compared with the input contact angles. FINDINGS: The impact of viscous dissipation on the energy balance is quantified; it is insignificant for water flooding in water-wet and mixed-wet media, resulting in an accurate estimation of a representative contact angle for the entire domain even if viscous effects are ignored. An increasing trend in the computed thermodynamic contact angle during water injection is shown to be a manifestation of the displacement sequence. Furthermore, the spatial distribution of wettability can be represented by the thermodynamic contact angle computed on a pore-by-pore basis.

Core versus cuttings samples for geochemical and petrophysical analysis of unconventional reservoir rocks.

Core samples from petroleum wells are costly to obtain, hence drill cuttings are commonly used as an alternative source of rock measurements for reservoir, basin modelling, and sedimentology studies. However, serious issues such as contamination from drilling mud, geological representativeness, and physical alteration can cast uncertainty on the results of studies based on cuttings samples. This paper provides a unique comparative study of core and cuttings samples obtained from both vertical and horizontal sections of a petroleum well drilled in the Canadian Montney tight gas siltstone reservoir to investigate the suitability of cuttings for a wide range of geochemical and petrophysical analyses. The results show that, on average, the bulk quantity of kerogen or solid bitumen measured in cuttings is comparable to that of the core samples. However, total organic carbon (TOC) measurements are influenced by oil-based drilling mud (OBM) contamination. Solvent-cleaning of cuttings has been shown to effectively remove OBM contamination in light, medium, and heavy range hydrocarbons and to produce similar kerogen/solid bitumen measurements to that of core samples. Similarly, pyrolysis methods provide an alternative to the solvent-cleaning procedure for analysis of kerogen/solid bitumen in as-received cuttings. Microscopic study substantiates the presence of significant contamination by OBM and caved organic and inorganic matter in the cuttings, which potentially influence the bulk geochemistry of the samples. Furthermore, minerals in the cuttings display induced micro-fractures due to physical impacts of the drilling process. These drilling-induced micro-fractures affect petrophysical properties by artificially enhancing the measured porosity and permeability.

A thermodynamically consistent characterization of wettability in porous media using high-resolution imaging.

Conservation of energy is used to derive a thermodynamically-consistent contact angle, θt, when fluid phase 1 displaces phase 2 in a porous medium. Assuming no change in Helmholtz free energy between two local equilibrium states we find that Δa1scosθt=κϕΔS1+Δa12, where a is the interfacial area per unit volume, ϕ is the porosity, S is the saturation and κ the curvature of the fluid-fluid interface. The subscript s denotes the solid, and we consider changes, Δ, in saturation and area. With the advent of high-resolution time-resolved three-dimensional X-ray imaging, all the terms in this expression can be measured directly. We analyse imaging datasets for displacement of oil by water in a water-wet and a mixed-wet sandstone. For the water-wet sample, the curvature is positive and oil bulges into the brine with almost spherical interfaces. In the mixed-wet case, larger interfacial areas are found, as the oil resides in layers. The mean curvature is close to zero, but the interface tends to bulge into brine in one direction, while brine bulges into oil in the other. We compare θt with the values measured geometrically in situ on the pore-scale images, θg. The thermodynamic angle θt provides a robust and consistent characterization of wettability. For the water-wet case the calculated value of θt gives an accurate prediction of multiphase flow properties using pore-scale modelling.

Quantification of Uncertainty and Best Practice in Computing Interfacial Curvature from Complex Pore Space Images.

Recent advances in high-resolution three-dimensional X-ray CT imaging have made it possible to visualize fluid configurations during multiphase displacement at the pore-scale. However, there is an inherited difficulty in image-based curvature measurements: the use of voxelized image data may introduce significant error, which has not-to date-been quantified. To find the best method to compute curvature from micro-CT images and quantify the likely error, we performed drainage and imbibition direct numerical simulations for an oil/water system on a bead pack and a Bentheimer sandstone. From the simulations, local fluid configurations and fluid pressures were obtained. We then investigated methods to compute curvature on the oil/water interface. The interface was defined in two ways; in one case the simulated interface with a sub-resolution smoothness was used, while the other was a smoothed interface extracted from synthetic segmented data based on the simulated phase distribution. The curvature computed on these surfaces was compared with that obtained from the simulated capillary pressure, which does not depend on the explicit consideration of the shape of the interface. As distinguished from previous studies which compared an average or peak curvature with the value derived from the measured macroscopic capillary pressure, our approach can also be used to study the pore-by-pore variation. This paper suggests the best method to compute curvature on images with a quantification of likely errors: local capillary pressures for each pore can be estimated to within 30% if the average radius of curvature is more than 6 times the image resolution, while the average capillary pressure can also be estimated to within 11% if the average radius of curvature is more than 10 times the image resolution.

Helicobacter pylori induces mono-(adenosine 5'-diphosphate)-ribosylation in human gastric adenocarcinoma.

Mono-(adenosine 5'-diphosphate) (ADP)-ribosylation, which transfers an ADP-ribose from nicotinamide adenine dinucleotide (NAD) to an acceptor protein, is an important post-translational modification of cellular proteins. Several bacterial toxins are known to possess the mono-ADP-ribosyltransferase activity to catalyze this reaction as a possible pathogenic factor. Therefore, the aim of this study was to examine whether H. pylori may also induce mono-ADP-ribosylation in a human gastric mucosal protein in association with gastric cancer development. Tumorous and adjacent non-tumorous mucosal tissue specimens were obtained from the surgically removed stomachs of 5 patients with gastric adenocarcinoma, and then were homogenized into cytosolic and membranous fractions. Each homogenate or an H. pylori extract was assayed for mono-ADP-ribosylation with [adenylate-(32)P]-NAD and 3-aminobenzamide, a potent inhibitor of poly-ADP-ribosylation. The radiolabeled proteins were separated by sodium dodecylsulfate-polyacrylamide gel electrophoresis followed by radio-image analysis. In the extracts from H. pylori, a strain-dependent, endogenous radiolabeling of 70-kDa protein was detected. An assay of the membranous fractions from 5 gastric adenocarcinomas with the extract of OMH4, a clinical H. pylori isolate, revealed notable radiolabelings of 55- and 45-kDa proteins, which were not found without the OMH4 extract. In contrast, the radiolabelings were minimal in the membranous fractions from respective non-tumorous mucosae, and they were not detected in any of the examined cytosolic fractions. All three radiolabelings of 70-, 55-, and 45-kDa proteins were dependent on NAD, but not on ADP-ribose. Snake venom phosphodiesterase digestion of the 3 radiolabeled proteins released only AMP. We thus found that H. pylori had an enzymatic mono-ADP-ribosyltransferase activity which enabled it to modify the 55- and 45-kDa membranous proteins of human gastric adenocarcinoma, as well as the 70-kDa protein of H. pylori itself. The possible roles underlying our observations on carcinogenesis or development of human gastric carcinoma are yet to be elucidated.

Assessment for diagnosis of lymph node metastasis in esophageal cancer using endoscopic ultrasound elastography.

BACKGROUND: We performed endoscopic ultrasound real-time tissue elastography to more accurately diagnose lymph node metastasis of esophageal cancer. The aim of this study was to evaluate the ability of EUS elastography to distinguish benign from malignant lymph nodes in esophageal cancer patients. METHODS: The present study had two steps. As the first step (study 1), we developed diagnostic criteria for metastatic lymph nodes using elastography and verified the validity of the criteria. Three hundred and twenty-two lymph nodes from 35 patients treated by surgical resection were included in the study. As the second step (study 2), we preoperatively examined the lymph nodes of esophageal cancer patients with EUS elastography and compared its diagnostic performance with that of the conventional B-mode EUS images. A total of 115 lymph nodes from 31 patients were included. RESULTS: In study 1, lymph nodes were considered malignant if 50 % or more of the node appeared blue, or if the peripheral part of the lesion was blue and the central part was red/yellow/green. The sensitivity and specificity of the elastography were 79.7 and 97.6 % with an accuracy of 93.8 %, which was significantly higher than the values for conventional B-mode imaging. In study 2, the sensitivity and specificity of the EUS elastography were 91.2 and 94.5 % with an accuracy of 93.9 %, which was also significantly higher than the values for conventional B-mode EUS imaging. CONCLUSIONS: The present study demonstrated that EUS elastography is useful for diagnosing lymph node metastasis of esophageal cancer.

High en bloc resection rate achieved by endoscopic mucosal resection with IT knife for early gastric cancer.

BACKGROUND/AIMS: Circumferential endoscopic mucosal resection (EMR) around lesions performed by an insulation-tipped diathermic knife (IT knife) increases en bloc resection rates, suggesting the possibility of expanding indications for EMR. METHODOLOGY: Clinical outcome of EMR performed by IT knife under general anesthesia was evaluated for 26 patients with 29 early gastric cancer. RESULTS: Successful en bloc resection rates obtained by the IT knife were 100, 87.5, 90.0 and 100% for lesions < or =10 mm in size, 11-20 mm, 21-30 mm, and > or =31 mm, respectively. They were significantly higher with the IT knife than those obtained by the conventional method (IT knife method: 93.1% vs. conventional method: 28.5%, p<0.0001). Two lesions were lateral margin positive, and in three cases invasion of lesions was observed as deep as the submucosa. Distal, total, and proximal gastrectomy with D2 lymphadenectomy, respectively, was provided in 3 cases; however, no lymph node involvement was found in any of the resected specimens. Bleeding and perforation were observed in 3 cases, respectively, however, no additional surgical treatment was required for these patients. CONCLUSIONS: EMR by means of the IT knife under general anesthesia can be performed safely and adequately. It is a useful treatment modality for early gastric cancer.

Monitoring salivary amylase activity is useful for providing timely analgesia under sedation.

AIM: To detect the criteria and cause of elevated salivary amylase activity (sAMY) in patients undergoing endoscopic submucosal dissection (ESD) under sedation. METHODS: A total of 41 patients with early gastric cancer removed via ESD under deep sedation (DS) were enrolled. The perioperative sAMY, which was shown as sympathetic excitements (SE), was measured. The time at which a patient exhibited a relatively increased rate of sAMY compared with the preoperative baseline level (IR, %) ≥ 100% (twice the actual value) was assumed as the moment when the patient received SE. Among the 41 patients, we focused on 14 patients who exhibited an IR ≥ 100% at any time that was associated with sAMY elevation during ESD (H-group) and examined whether any particular endoscopic procedures can cause SE by simultaneously monitoring the sAMY level. If a patient demonstrated an elevated sAMY level above twice the baseline level, the endoscopic procedure was immediately stopped. In the impossible case of discontinuance, analgesic medicines were administered. This study was performed prospectively. RESULTS: A total of 26 episodes of sAMY eruption were considered moments of SE in the H-group. The baseline level of sAMY significantly increased in association with an IR of > 100% at 5 min, with a significant difference (IR immediately before elevation/IR at elevation of sAMY = 8.72 ± 173/958 ± 1391%, P < 0.001). However, effective intervention decreased the elevated sAMY level immediately within only 5 min, with a significant difference (IR at sAMY elevation/immediately after intervention = 958 ± 1391/476 ± 1031, P < 0.001). The bispectral indices, systolic blood pressure and pulse rates, which were measured at the same time, remained stable throughout the ESD. Forceful endoscopic insertion or over insufflation was performed during 22 of the 26 episodes. Release of the gastric wall tension and/or the administration of analgesic medication resulted in the immediate recovery of the elevated sAMY level, independent of body movement. CONCLUSION: By detecting twice the actual sAMY based on the preoperative level, the release of the gastric wall tension or the administration of analgesic agents should be considered.

Rapid diagnosis of micrometastasis of gastric cancer using reverse transcription loop-mediated isothermal amplification.

Methods to detect metastases in biopsy specimens with certain rapidity and accuracy are essential to performing tailor-made surgeries for solid malignancies. Reverse transcription loop-mediated isothermal amplification (RT-LAMP) reaction is a novel technique for detecting mRNA expression of target sequences with high sensitivity and rapidity, even from crude samples without RNA purification. Applicability to detect lymph node (LN) micrometastasis of gastric cancer was tested. Total of 26 LNs were retrieved from 10 patients with primary gastric cancer. Each LN was serially sectioned, and every set of three serial sections were tested for routine histopathological (H&E) and immunohistochemical examination with anti-cytokeratin antibodies (IHC), and RT-LAMP analysis targeted cytokeratin 19 mRNA. Results from H&E/IHC and RT-LAMP analysis were compared in each set of sections. All the sections of those containing metastatic lesions equivalent to a volume of overt metastasis (maximum diameter>2 mm), 90% of those containing micrometastasis (between 2 and 0.2 mm) and 83% of those containing isolated tumor cells (<0.2 mm) were detectable using this procedure. Total analysis from lysates of clinical specimens required<75 min. This new technique is suggested to be an alternative to rapid diagnosis of micrometastasis based on conventional histopathological analysis.

Postoperative recurrence of an IPMN of the pancreas with a fistula to the stomach.

We report on a case of a 74 year old man who was diagnosed with a recurrence of non-invasive carcinoma of intraductal papillary mucinous neoplasm (non-invasive IPMN) by postoperative gastroscopy (GS). A pylorus preserving pancreatico duodenectomy for IPMN in the pancreatic head was performed. A histopathological study revealed non-invasive adenocarcinoma. At first, the local recurrence of the tumor around the superior mesenteric artery circumference was diagnosed and disappeared with gemcitabine. Later, the GS showed the elevated lesion with mucin hypersecretion in the remnant stomach. The lesion had a central dip and a fistula common to the pancreas was confirmed on fisterography. We diagnosed a recurrence of IPMN and administered chemotherapy again. However, he died of his original illness. There are no reports of postoperative recurrence of IPMN checked by GS. It should be remembered that the elevated lesion of the remnant stomach is considered as one of the recurrent patterns of IPMN.