The influence of serum cholinesterase levels and sarcopenia on postoperative infectious complications in colorectal cancer surgery.

PURPOSE: Cholinesterase is a nutritional marker associated with sarcopenia. The present study evaluated the relationship between cholinesterase and postoperative infectious complications in patients undergoing colorectal resection for colorectal cancer. METHODS: The study involved 231 patients who had undergone colorectal resection for colorectal cancer. We retrospectively investigated the relationship between preoperative serum cholinesterase levels and postoperative infectious complications. Univariate and multivariate analyses were performed to identify independent risk factors for postoperative infectious complications. We then performed stratified analyses to assess the interaction between cholinesterase and clinical variables to predict postoperative infectious complications. RESULTS: In the multivariate analysis, the body mass index (P = 0.010), serum cholinesterase levels (P = 0.005), sarcopenia (P = 0.003) and blood loss (P < 0.001) were independent risk factors for postoperative infectious complications. In stratified analyses, the association between serum cholinesterase levels and postoperative infectious complications differed by the sarcopenia status (Pinteraction = 0.006). CONCLUSION: Preoperative serum cholinesterase levels may be useful for predicting postoperative infectious complications in colorectal cancer surgery. The association differs by the sarcopenia status, suggesting a potential interaction between nutritional markers and sarcopenia.

The impact of low serum cholinesterase levels on survival in patients with colorectal cancer.

PURPOSE: Nutritional and inflammatory status have been associated with postoperative recurrence and poor survival in patients with colorectal cancer. The aim of the present study is to investigate the relationship between serum cholinesterase levels and postoperative outcomes among patients who underwent curative resection for colorectal cancer. METHODS: The study comprised 174 patients who had undergone curative resection for colorectal cancer. We explored the relationship between preoperative serum cholinesterase levels and disease-free survival and overall survival after curative resection. Then patients were divided into the high-cholinesterase group (n = 102) and the low-cholinesterase group (n = 72) to analyze their clinicopathological variables including other nutritional markers and systemic inflammatory responses. RESULTS: In multivariate analysis, lymph node metastasis (P = 0.011) and serum cholinesterase levels (P < 0.01) were independent predictors of disease-free survival, while lymph node metastasis (P = 0.013), serum cholinesterase levels (P < 0.01), and carbohydrate antigen19-9 (P = 0.022) were independent predictors of overall survival. In the low-cholinesterase group, neutrophil to lymphocyte ratio, (P = 0.021), C-reactive protein to albumin ratio (P < 0.01), and distant metastasis (P < 0.01) were higher, and prognostic nutritional index (P < 0.01) was lower compared with the high-cholinesterase group. CONCLUSION: Preoperative low serum cholinesterase levels can be a prognostic factor for postoperative recurrence and poor prognosis in patients after curative resection for colorectal cancer, suggesting an important role of cholinesterase in the assessment of nutritional and inflammatory status in cancer patients.

Preoperative serum cholinesterase levels as a risk factor of postoperative complications for the elderly undergoing emergency surgery.

PURPOSES: An accurate assessment of preoperative malnutrition in the elderly is critically important to predicting postoperative complications. The aim of this study is to evaluate the predictive value of the preoperative serum cholinesterase levels as a risk factor for postoperative complications in the elderly who have undergone emergency surgery. METHODS: The study comprised 60 elderly patients who had undergone emergency major gastroenterological surgery. We retrospectively investigated the relationship between the preoperative serum cholinesterase levels and postoperative complications (Clavien-Dindo classification ≥ II). Univariate and multivariate analyses were performed to evaluate the risk factors for postoperative complications. RESULTS: Thirty-three patients (55%) developed postoperative complications. According to the univariate analysis, hemoglobin (P = 0.018), albumin (P = 0.0036), cholinesterase (P < 0.001), C-reactive protein (P = 0.043), prognostic nutritional index (P = 0.0050), the Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (P < 0.001) and operation time (P = 0.042) were identified to be risk factors for postoperative complications. According to the multivariate analysis, low preoperative serum cholinesterase levels were found to be an independent risk factor for postoperative complications (P = 0.029). In the extremely elderly (80-95 years), the cholinesterase-low group had a higher complication rate compared to the cholinesterase-high group (77.8 vs 43.8%, P = 0.028). CONCLUSION: The preoperative serum cholinesterase levels may be a risk factor for postoperative complications in elderly patients after emergency surgery, thus suggesting the significance of cholinesterase in evaluating the nutritional status.

Reasons and risk factors for intraoperative conversion from laparoscopic to open cholecystectomy.

PURPOSE: The aim of this study was to analyze the reasons and risk factors for intraoperative conversion from laparoscopic cholecystectomy to open cholecystectomy. METHODS: The study involved 407 patients in whom laparoscopic cholecystectomy was planned between January 1998 and July 2006. The patients were divided into two groups (the LC completed group and the conversion group), and the two groups were compared. RESULTS: Laparoscopic surgery was intraoperatively converted to open surgery in 47 cases (11.6 %). The reasons for the conversion consisted of adhesions (15 cases), inflammation (8 cases), adhesion plus inflammation (9 cases), bleeding (8 cases), common bile duct injury (4 cases), suspected common bile duct injury (1 case), injury of the duodenal bulb (1 case) and respiratory disorder (1 case). The group of patients who required conversion to open surgery had a significantly higher percentage of males (P = 0.042) and prevalence of acute cholecystitis (P < 0.001) than the group of patients for whom laparoscopic surgery could be completed. A multivariate logistic regression analysis of these significant predictors showed that male sex [odds ratio (OR) 1.95] and acute cholecystitis (OR 8.45) were significant. CONCLUSION: Particular attention is needed when laparoscopic surgery is considered for male patients with acute cholecystitis.

Successful adjuvant bi-weekly gemcitabine chemotherapy for pancreatic cancer without impairing patients' quality of life.

BACKGROUND: Although adjuvant gemcitabine (GEM) chemotherapy for pancreatic cancer is standard, the quality of life (QOL) in those patients is still impaired by the standard regimen of GEM. Therefore, we studied whether mild dose-intensity adjuvant chemotherapy with bi-weekly GEM administration could provide a survival benefit with acceptable QOL to the patients with pancreatic cancer. METHODS: After a phase I trial, an adjuvant bi-weekly 1,000 mg/m2 of GEM chemotherapy was performed in 58 patients with pancreatic cancer for at least 12 courses (Group A). In contrast, 36 patients who declined the adjuvant bi-weekly GEM chemotherapy underwent traditional adjuvant 5FU-based chemotherapy (Group B). Careful periodical follow-ups for side effects of GEM and disease recurrence, and assessment of patients' QOL using the EORTC QOL questionnaire (QLQ-C30) and pancreatic cancer-specific supplemental module (QLQ-PAN26) were performed. Retrospectively, the degree of side effects, patients' QOL, compliance rate, disease-free survival (DFS), and overall survival (OS) in Group A were compared with those in Group B. RESULTS: No severe side effects (higher than Grade 2 according to the common toxicity criteria of ECOG) were observed, except for patients in Group B, who were switched to the standard GEM chemotherapy. Patients' QOL was better in Group A than B (fatigue: 48.9 ± 32.1 versus 68.1 ± 36.3, nausea and vomiting: 26.8 ± 20.4 versus 53.7 ± 32.6, diarrhea: 21.0 ± 22.6 versus 53.9 ± 38.5, difficulty gaining weight: 49.5 ± 34.4 versus 67.7 ± 40.5, P < 0.05). Compliance rates in Groups A and B were 93% and 47%. There was a significant difference in the median DFS between both groups (Group A : B =12.5 : 6.6 months, P < 0.001). The median OS of Group A was prolonged markedly compared with Group B (20.2 versus 11.9 months, P < 0.005). For OS between both groups, univariate analysis revealed no statistical difference in 69-year-old or under females, and T1-2 factors, moreover, multivariate analysis indicated three factors, such as bi-weekly adjuvant GEM chemotherapy, T2 or less, and R0. CONCLUSIONS: Adjuvant chemotherapy with bi-weekly GEM offered not only the advantage of survival benefits but the excellent compliance with acceptable QOL for postoperative pancreatic cancer patients.

Laparoscopic surgery for duodenal perforation due to a diverticulum with heterotopic pancreas: a case report.

BACKGROUND: Heterotopic pancreas (HP) refers to the presence of abnormally located pancreatic tissue without any anatomic or vascular continuity with the main body of the pancreas. HP can occur in the gastrointestinal tract and be complicated by gastrointestinal bleeding, pancreatitis, obstruction, or malignant generation. Specifically, perforation of the gastrointestinal tract because of HP is extremely rare. CASE PRESENTATION: A 91-year-old woman was diagnosed with duodenal perforation, and an emergency laparoscopic operation was performed. The operative findings indicated a tumor and duodenal wall perforation. The tumor and the perforated site were resected with a linear stapler. Histopathological examination revealed the presence of HP tissue in the submucosal layer around the diverticulum without any signs of inflammation. The perforated site was not covered by HP tissues, and the duodenal wall might have been weaker than the other areas, which could have caused the internal pressure to increase and led to the perforation. CONCLUSIONS: Preoperative HP diagnosis is difficult, and it is crucial to consider HP as the differential diagnosis in gastrointestinal perforations. The duodenal diverticula can be perforated due to increased internal pressure of the duodenum caused by the imbalanced localization of HP.

Significance of osteopenia in elderly patients undergoing emergency gastrointestinal surgery.

Aim: Frailty assessment in elderly patients is crucial to predict the postoperative course, considering that frailty is highly associated with postoperative complications and mortality. The aim of this study was to evaluate the value of osteopenia as a risk factor for severe postoperative complications in elderly patients who underwent emergency gastrointestinal surgery. Methods: This study comprised 103 elderly patients who underwent emergency gastrointestinal surgery. Osteopenia was diagnosed by measuring bone mineral density, which was calculated as the average pixel density in the midvertebral core at the 11th thoracic vertebra on the preoperative plain computed tomography image. We retrospectively investigated the relationship between preoperative osteopenia and severe postoperative complications (Clavien-Dindo classification ≥III). Univariate and multivariate analyses were performed to evaluate the risk factors for severe postoperative complications. Results: Twenty-three patients (22.3%) developed severe postoperative complications. The optimal cutoff value of bone mineral density for severe postoperative complications was 119.5 Hounsfield unit (HU) and 39 patients (37.9%) were diagnosed with osteopenia. The univariate analysis revealed that the American Society of Anesthesiologists Physical Status of ≥3 (P = .0084), hemoglobin levels (P = .0026), albumin levels (P < .001), sarcopenia (P = .015), and osteopenia (P < .001) were significantly associated with severe postoperative complications. The multivariate analysis showed that osteopenia (P = .014) was an independent risk factor for severe postoperative complications. Conclusion: Osteopenia may be a risk factor for severe postoperative complications in elderly patients after emergency gastrointestinal surgery.

Suture granuloma with hydronephrosis caused by ileostomy closure after rectal cancer surgery: a case report.

BACKGROUND: Suture granuloma with hydronephrosis after abdominal surgery is extremely rare. We herein report a successfully treated case of suture granuloma with hydronephrosis caused by ileostomy closure after rectal cancer surgery. CASE PRESENTATION: A 63-year-old male underwent laparoscopic low anterior resection with covering ileostomy. Two months after primary operation, ileostomy closure was performed with two layered hand-sewn suture (Albert-Lembert method) using absorbable suture. In that operation, marginal blood vessels in the mesentery were ligated with silk suture. The patient had remained in remission with no evidence of tumor recurrence, however, 2 years and 5 months after primary surgery, a contrast-enhanced computed tomography (CT) scan showed a mass-forming lesion on the right external iliac artery (43 × 26 mm) and hydronephrosis. Positron emission tomography/computed tomography (PET/CT) showed a mass-forming lesion without high accumulation, which obstructed the right ureter. Recurrence could not be ruled out due to the rapid appearance of tumor and hydronephrosis in the short-term period. Thus, the patient underwent laparotomy. The tumor located in the mesentery near the anastomosis of ileostomy closure and it was strongly adherent to the retroperitoneum, which obstructed the right ureter. The adhesion between the tumor and ureter was carefully dissected and tumor resection with partial small bowel resection was then performed with preservation of the ureter using ureteral stents. Pathological examination of the tumor revealed fibrous proliferation of foreign body granuloma. In the resected tumor, sutures with foreign giant cells were found. Therefore, we diagnosed the tumor as silk suture granuloma, which was caused by the silk suture used to ligate blood vessels of the mesentery at the ileostomy closure. The patient remained well with no evidence of tumor recurrence as 5 years after the primary operation of rectal cancer. CONCLUSIONS: Suture granuloma is a rare surgery-related complication in the postoperative surveillance of patients with colorectal cancer. If suture granuloma mimicking local recurrence is a differential diagnosis, it would be important to consider to avoid unnecessary extended resection.

Hemangiopericytoma of the greater omentum.

A 41-year-old Chinese woman was admitted to our hospital with epigastric pain. Computed tomography detected a heterogeneous enhancement tumor fed by the left gastroepiploic artery in the left lower quadrant and cholelithiasis. Excision of the tumor in the greater omentum and cholecystectomy were performed laparoscopically. Histological findings confirmed a diagnosis of hemangiopericytoma with low-grade malignancy. To our knowledge, hemangiopericytoma of the greater omentum is very rare, and only 12 cases were reported in English literature. We report a case of hemangiopericytoma arising in the greater omentum and review the literature.

Successful new method of extracorporeal percutaneous endoscopic gastrostomy (E-PEG).

BACKGROUND: Although percutaneous endoscopic gastrostomy (PEG) has become popular for patients with swallowing disorders as a nutrition support or a decompressant of gastrointestine, perioperative complications associated with PEG have not decreased, especially peristomal infections. To reduce peristomal infections, we designed a new method of gastrostomy by extracorporeal approach under endoscopic observation, named as extra-corporeal PEG (E-PEG). METHODS: Experimental studies for E-PEG were performed repeatedly using pigs under general anesthesia to confirm the safety of its procedure for human use. After approval of institutional ethics review board in our university, thirty patients with prior consent participated in this study. The operation time, the incidence rate of complications and the hospital stay were compared between E-PEG and ordinary pull-method PEG groups. RESULTS: Two patients (6.7%) in E-PEG group had postoperative complications, i.e., aspiration pneumonia and surgical site infection. The operation time of E-PEG group was 5-16 (mean +/- SD: 10.3 +/- 2.96) min as compared to 14-37 (mean +/- SD: 26.9 +/- 8.39) min with pull-method PEG. The postoperative hospital day of E-PEG was within two days except for the two complicated cases. Significance differences of operation time, complication rate and postoperative hospital stay between those groups observed statistically. CONCLUSIONS: These results indicate that E-PEG was safe, tolerable and speedy when compared ordinary pull-method PEG.

Huge cavernous hemangioma arising in a male breast.

We report a rare case of a huge cavernous hemangioma arising in a male breast. A 60-year-old man first noticed 1 x 2 cm elastic hard nodule just below his right nipple ten years previously. It enlarged 5 x 5 cm over six years. When he came to our clinic, it was size of child head (510 mm in circumference),was an elastic hard with a rather smooth surface, and firmly fixed to the chest wall. Magnetic resonance imaging (MRI) and multidetectocomputed tomography (MDCT)showed a large mass infiltrating into the chest wall. Fine needle aspiration cytology (FNA) and core needle biopsy (CNB) failed to obtain proper material except for old bloody fluid or necrotic connective tissue, precluding a correct diagnosis preoperatively. Mastectomy with partial resection of the chest wall was subsequently performed. Histologically, it was found to be a cavernous hemangioma without cellular atypia. In such a case, complete excision is recommended to exclude the possibility of an underlying malignant lesion.

Desensitization of NFκB for overcoming chemoresistance of pancreatic cancer cells to TNF-α or paclitaxel.

BACKGROUND: Chemotherapy-induced nuclear factor kappaB (NFκB) activation is thought to play a key role in acquisition of chemoresistance by cancer cells. We focused on blockade of this activation by using the observation so-called 'desensitization' of NFκB using known NFκB activator, doxycycline. MATERIALS AND METHODS: The human pancreatic cancer cell line PANC-1 was incubated with doxycycline, followed by treatment with tumor necrosis factor (TNF)-α or paclitaxel. NFκB activity and the regulation of NFκB-related genes was analyzed. RESULTS: Doxycycline induced sustained NFκB activation, followed by desensitization to further NFκB activation by TNF-α -or paclitaxel, which was accompanied by decreased expression of TNF receptor p55, p75, and epidermal growth factor receptor. Consistent with these observations, doxycycline-pre-treatment resulted in an augmentation of TNF-α- and paclitaxel-mediated cytotoxicity and apoptosis. CONCLUSION: These data indicate the possible clinical application of desensitization of NFκB to overcome chemoresistance by conventional chemotherapy for pancreatic cancer.

Doxycycline induces apoptosis in PANC-1 pancreatic cancer cells.

BACKGROUND: Tetracyclines such as doxycycline are reported to possess cytotoxic activity against mammalian tumor cells, but the mechanism of their effects on cell proliferation remains unclear. MATERIALS AND METHODS: The antitumor effect of doxycycline was investigated in human pancreatic cancer cell line, PANC-1. We also investigated the effect of doxycycline on expression of a potent proangiogenic factor, interleukin (IL)-8. RESULTS: In excess of 20 microg/ml, cytotoxic effects of doxycycline were accompanied by G(1)-S cell cycle arrest and DNA fragmentation in PANC-1 cells. Doxycycline consistently activated transcription of p53, p21 and Fas/FasL-cascade-related genes, while reducing the expression of Bcl-xL and Mcl-1. Doxycycline (5 microg/ml) below the cytotoxic level suppressed endogenous and paclitaxel-induced IL-8 expression. In the mouse xenograft model, doxycycline treatment was shown to suppress tumor growth by 80%. CONCLUSION: These data suggest that doxycycline exerts its antitumor effect by activating proapoptotic genes, inhibiting IL-8 expression, and suppressing antiapoptotic genes.

Three-Port laparoscopic partial hepatectomy using an ultrasonically activated device (USAD).

BACKGROUND/PURPOSE: We provide an initial report of the indications and procedure for three-port laparoscopic partial hepatectomy. METHODS: Three-port laparoscopic partial hepatectomy was performed in nine patients (age, 49 to 73 years) at our department. Eight patients (seven men and one woman) had hepatocellular carcinoma (HCC); six of these patients had liver cirrhosis (LC) and two had chronic hepatitis (CH). The ninth patient, a woman had a single metastatic liver tumor from colon cancer. The tumors were located in regons S(2), S(3), S(4), S(5), S(6), and S(8). Preoperative liver function assessment revealed Child-Pugh classification A or B. All the tumors were located superficially, and their diameter averaged approximately 3 cm. Hepatectomy was performed laparoscopically, using an ultrasonically activated device (USAD) with or without microwave coagulation therapy (MCT). RESULTS: The operative time was 50 to 168 min, and the intraoperative blood loss ranged from 32 to 158 g. The postoperative hospital stay was 5 to 17 days. No recurrences, including local relapse, were observed. CONCLUSIONS: Three-port laparoscopic partial hepatectomy is safe and feasible for patients with Child-Pugh liver function classification A or B if the tumor is located superficially and is less than 3 cm in diameter.

Analysis of bile duct injuries (Stewart-Way classification) during laparoscopic cholecystectomy.

In order to investigate mechanisms underlying the occurrence of bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC), we analyzed results for 34 patients (0.59%; 17 men, 17 women; average age, 57 years) with BDI out of 5750 LCs, based on questionnaire responses from surgical operators, records of direct interviews with these operators, operative reports, and videotapes of the operations. The indications for LC in the 34 patients were chronic cholecystitis in 32 patients and acute cholecystitis in 2. The BDIs in these patients were divided into four classes using the Stewart-Way classification: class I, incision (incomplete transection) of the common bile duct (CBD), n = 6 (17.6%); class II, lateral damage to the common hepatic duct (CHD), n = 9 (26.5%); class III, transection of the CBD or CHD, n = 15 (44.1%); and class IV, right hepatic duct or right segmental hepatic duct injuries, n = 4 (11.8%). In all class III and 3 class I cases (18 in total; incidence 53%), the mistake involved misidentifying the CBD as the cystic duct. Of all types (classes) of injuries, class III injuries showed the mildest gallbladder inflammation, and there was a significant (P = 0.0005) difference in the severity of inflammation between class II and III injuries. We conclude that complete transection of the CBD, which is rare in laparotomy, was the most common BDI pattern occurring during LC and that the underlying factor in the operator making this error was mistaking the CBD for the cystic duct.