[Simultaneous bilateral spontaneous pneumothorax; report of a case].

Simultaneous bilateral spontaneous pneumothorax (SBSP) occurred in a 16-year-old male. He presented with severe dyspnea. Chest X-ray showed bilateral pneumothorax. Computed tomography revealed bilateral apical bullas. Chest tubes were promptly inserted bilaterally. The patient underwent single-stage bilateral video-assisted thoracoscopic surgery( VATS). Bilateral bullectomy was performed sequentially. Saline poured in to test for air leakage did not escape to the opposite pleural cavity, suggesting no pleuro-pleural communication. Post-operative course was uneventful. A bilateral single-stage VATS by a conventional lateral approach with intra-operative patient repositioning is a safe, feasible and familiar technique for treatment of SBSP.

[Diaphragmatic eventration with shock and respiratory distress requiring emergency plication; report of a case].

A 80-year-old female with an eventration of the left diaphragm, which had been noticed with routine chest roentgenogram in 2006, presented with severe dyspnea and shock vital in 2012. The chest X-ray on admission disclosed elevation of the left hemidiaphragm, dislocation of the heart to the right. The diagnosis of eventration of the diaphragm was confirmed with a computed tomographic scan. She underwent diaphragmatic plication with endostaplers by thoracoscopic surgery. The postoperative course was uneventful except for transient reexpansion pulmonary edema. The patient was extubated on the 5th postoperative day. Dyspnea has disappeared after the operation. She was in a good condition without requiring any additional oxygen.

Voice restoration by primary insertion of indwelling voice prosthesis following circumferential pharyngolaryngectomy with free jejunal graft.

BACKGROUND: Voice restoration after circumferential pharyngolaryngectomy (CPL) with free jejunal graft remains a difficult problem to solve. Few reports have analyzed the success rate and complications following primary insertion of indwelling voice prostheses during CPL with free jejunal graft. PATIENTS AND METHODS: Eight patients who underwent CPL with free jejunal graft had a Groningen voice prosthesis inserted as a tracheoesophageal (TE) shunt at the time of oncological surgery. A 10-point scale was used to assess each patient's speech intelligibility. Complications following the voice prosthesis insertion were also analyzed. RESULTS: Six of the eight patients (75%) achieved excellent speech intelligibility and the remaining two patients (25%) were judged as moderate. Six of the eight patients (75%) used the TE shunt as their major means of daily communication. Leakage through or around the prosthesis, which occurred in six (75%) patients, was the most frequent prosthesis-related complication. CONCLUSIONS: This safe and reliable technique can be effective in improving the quality of life in selected patients undergoing CPL.

Prediction of lymph node metastasis and perineural invasion of biliary tract cancer by selected features from cDNA array data.

OBJECTIVE: To better understand the nature of the malignancy of biliary tract carcinoma and evaluate the feasibility of its prediction by gene expression profiles. METHODS AND RESULTS: We explored the gene expression profiles characteristic of progression and invasiveness in the cDNA array data obtained from 37 biliary tract carcinomas (15 bile duct, 11 gallbladder, 11 of ampulla of Vater). We pre-selected 51 and 100 genes for the presence versus absence of lymph node metastasis and perineural invasion on the basis of statistical difference. To search optimized sets of genes for prediction, we applied a sequential forward feature selection, minimizing leave-one-out error rates on a k-nearest neighbor classifier. We could predict lymph node metastasis and perineural invasion with an accuracy of 94 and 100%, respectively. When the 6-stage IA cancers without perineural invasion were precluded, a marked difference in gene expression (147 gene), discriminable with 100% accuracy, was noted between positive versus negative perineural invasion, suggesting that the acquisition of invasive character is rather a later molecular pathological event in biliary tract cancer. CONCLUSION: The present method provides a powerful means of classifying biliary tract carcinomas. We also suggest that perineural invasion is an important target of array databased pattern classification, which may predict patient outcomes and facilitate the determination of the extent of surgery to minimize the risk of recurrence.

Prediction of lymph node metastasis by analysis of gene expression profiles in non-small cell lung cancer.

OBJECTIVE: Non-small cell lung carcinoma (NSCLC) is one of the leading causes of death in the world. Lymph node metastasis is not only an important factor in estimating the extent and the metastatic potential of an NSCLC but also in prognosticating the patient outcome. Preoperative prediction of lymph node metastasis might greatly facilitate the choice of appropriate surgical and medical options in patients with NSCLC. METHODS AND RESULTS: Using a cDNA array, we analyzed the expression profiles of 1,289 genes in 92 cancer tissues of NSCLC (37 squamous cell carcinomas and 55 adenocarcinomas). We divided the patients into two groups (classes) for each of various pathological factors, such as lymph node metastasis and pT-stage. For each pair of classes, we searched for an optimal combination of genes to classify the cases using a sequential forward selection algorithm starting from a gene set that showed significant difference in expression between the classes. We used the leave-one-out error cross-validation on a k-nearest neighbor classifier to sequentially choose the gene. Using the optimized set of genes, it was possible to stratify the patients for lymph node metastasis (pN-stage) and pT-stage at, respectively, 100% (23 genes) and 100% (55 genes) for cases with squamous cell carcinomas and 94% (43 genes) and 92% (35 genes) for those with adenocarcinomas. CONCLUSION: We conclude that expression profiling using feature selection provides a powerful means of stratification (personalization) of NSCLC patients and choice in treatment options, particularly for factors such as lymph node metastasis whose radiological diagnosis is presently incomplete.

Laparoscopic Nissen fundoplication for gastroesophageal reflux disease in Japan.

PURPOSE: Laparoscopic antireflux surgery is the standard treatment for gastroesophageal reflux disease (GERD) in Western countries where this disorder is common; however, it has only recently been introduced in Japan. We examined the effectiveness of laparoscopic antireflux surgery in a small series of Japanese patients. METHODS: Between 1998 and 2001 we performed laparoscopic Nissen fundoplication in 23 patients to evaluate the efficiency of this technique. We examined the following four parameters pre- and postoperatively: symptoms, endoscopic findings, gastroesophagogram findings, and the results of intraesophageal 24-h pH monitoring. We also examined the operation time, blood loss, intraoperative complications, and postoperative complications. RESULTS: The operation was safely performed in all patients, regardless of age, and there were no intraoperative complications. Postoperatively, more than three parameters were effectively normalized in 17 (89.5%) of 19 patients. The only postoperative complications were delayed gastric emptying in three patients and persistent dysphagia in five patients. During follow-up, esophagitis recurred in two patients, one of whom underwent laparoscopic refundoplication, which normalized the condition. CONCLUSION: Laparoscopic Nissen fundoplication is highly effective for GERD and could become the standard surgical treatment in Japan.

Gene-expression profile changes correlated with tumor progression and lymph node metastasis in esophageal cancer.

PURPOSE: The purpose of this research was to identify molecular clues to tumor progression and lymph node metastasis in esophageal cancer and to test their value as predictive markers. EXPERIMENTAL DESIGN: We explored the gene expression profiles in cDNA array data of a 36-tissue training set of esophageal squamous cell carcinoma (ESCC) by using generalized linear model-based regression analysis and a feature subset selection algorithm. By applying the identified optimal feature sets (predictive gene sets), we trained and developed ensemble classifiers consisting of multiple probabilistic neural networks combined with AdaBoosting to predict tumor stages and lymph node metastasis. We validated the classifier abilities with 18 independent cases of ESCC. RESULTS: We identified 71 genes of 1289 cancer-related genes of which the expression correlated with tumor stages. Of the 71 genes, 47 significantly differed between the Tumor-Node-Metastasis pT1/2 and pT3/4 stages. Cell cycle regulators and transcriptional factors possibly promoting the growth of tumor cells were highly expressed in the early stages of ESCC, whereas adhesion molecules and extracellular matrix-related molecules possibly promoting invasiveness increased in the later stages. For lymph node metastasis, we identified 44 genes with predictive values, which included cell adhesion molecules and cell membrane receptors showing higher expression in node-positive cases and cell cycle regulators and intracellular signaling molecules showing higher expression in node-negative cases. The ensemble classifiers trained with the selected features predicted tumor stage and lymph node metastasis in the 18 validation cases with respective accuracies of 94.4% and 88.9%. This demonstrated the reproducibility and predictive value of the identified features. CONCLUSION: We suggest that these characteristic genes will provide useful information for understanding the malignant nature of ESCC as well as information useful for personalizing the treatments.

Malignant pheochromocytoma associated with pseudo-obstruction of the colon.

Effective treatment has not yet been established for intestinal pseudo-obstruction, a rare complication of malignant pheochromocytoma. We report the case of a 41-year-old man who presented with malignant pheochromocytoma associated with pseudo-obstruction of the colon. His serum catecholamine level was markedly elevated, and his large intestine was distended with gas and lodged stool. Laxatives and enemas were not effective in relieving his symptoms. We subsequently performed an ileostomy, after which the patient had good bowel movement and was able to resume oral food intake.

Primary sclerosing cholangitis associated with autoimmune pancreatitis.

We present 2 cases of primary sclerosing cholangitis complicated with autoimmune pancreatitis with narrowing of the pancreatic duct. In both cases, endoscopic retrograde cholangiography showed the characteristic findings of primary sclerosing cholangitis. In addition, positivity for autoantibody, hypergamma-globulinemia and narrowing of the pancreatic duct shown on endoscopic retrograde pancreatography were noticed in both. They were thu diagnosed as autoimmune pancreatitis. Whereas it is well known that primary sclerosing cholangitis is often complicated with chronic pancreatitis, it has rarely been studied whether the chronic pancreatitis is autoimmune pancreatitis or not. In English literature, possibly 7 equivalent cases have been reported so far. In those cases, the onset was in the post-prime of life, and the disease was frequently accompanied with Sjögren's syndrome, but not with ulcerative colitis; frankly the nature of the disease was slightly different from what has traditionally been thought as a typical primary sclerosing cholangitis. In primary sclerosing cholangitis complicated with autoimmune pancreatitis, the autoimmune mechanism seems to be much involved, and thus steroid therapy might be effective as in Case 2 in our series.

Inflammatory pseudotumor of the mesentery causing portal venous thrombosis and cavernomatous transformation.

A 32-year-old man was admitted to our hospital complaining of abdominal pain in the left upper quadrant. A mass was palpable on the left side of the umbilicus. Laboratory data revealed anemia, elevated erythrocyte sedimentation rate, hypergammaglobulinemia, and prolonged prothrombin time. Computed tomography demonstrated a soft tissue mass in the mesentery of the jejunum, portal venous thrombosis, and cavernomatous transformation in the porta hepatis. The patient was eventually diagnosed by laparoscopic partial resection as having inflammatory pseudotumor of the mesentery. Four months later, all of his symptoms and abnormal laboratory findings completely disappeared without any therapy. Inflammatory pseudotumor should be kept in mind as a cause of portal venous thrombosis, and/or cavernomatous transformation although it is rare.