Safe approach to the splenic hilum by first mobilizing the pancreatic tail in laparoscopic splenectomy.

INTRODUCTION: We employed a safe approach during laparoscopic splenectomy by first mobilizing the pancreatic tail and then dissecting the splenic vessels at the splenic hilum before mobilizing the spleen. MATERIALS AND SURGICAL TECHNIQUE: Patients were placed in the lithotomy position, and only the upper body was twisted to the right side. Five trocars were placed. After the bursa omentalis was opened, an avascular layer was identified behind the pancreas. This avascular layer was bluntly dissected, and the pancreatic tail was isolated from the retroperitoneum. The tissue surrounding the splenic hilum was dissected by a handling tape that was placed around the pancreatic tail. Because the spleen remained connected to the retroperitoneum with the splenorenal ligament, a good operative view of the splenic hilum was obtained with proper extension. After sufficient space was secured between the pancreatic tail and the spleen, the splenic vessels were divided with a linear stapler. The spleen was detached in the final stage. DISCUSSION: The current standardized procedure is highly recommended for a safe laparoscopic splenectomy.

The "right" way is not always popular: comparison of surgeons' perceptions during laparoscopic cholecystectomy for acute cholecystitis among experts from Japan, Korea and Taiwan.

BACKGROUND: Generally, surgeons' perceptions of surgical safety are based on experience and institutional policy. Our recent pilot survey demonstrated that the acceptable duration of surgery and criteria for open conversion during laparoscopic cholecystectomy (LC) vary among workplaces. METHODS: A web-based survey was distributed to 554 expert LC surgeons in Japan, Korea, and Taiwan. The questionnaire covered LC experience, safety measures and recognition of landmarks, decision-making regarding conversion to open/partial cholecystectomy and the implications of this decision. Overall responses were compared among nations, and then stratified by LC experience level (lifetime cases 200-499, 500-999, and ≥1,000). RESULTS: The response rate was 92.6% (513/554); 67 surgeons with ≤199 LCs were excluded, and responses from 446 surgeons were analyzed. We observed significant differences among nations on almost all questions. Differences that remained after stratification by LC experience were on questions related to acceptable duration of surgery, adoption rates of intraoperative cholangiography, the "critical view of safety" technique, identification of Rouvière's sulcus, recognition of the SS-Inner layer theory, and intraoperative judgment to abandon conventional LC. CONCLUSIONS: Even among experts, surgeons' perceptions during LC are workplace-dependent. A novel grading system of surgical difficulty and standardized LC procedures are paramount to generate high-level evidence.

[Neoadjuvant Chemotherapy Using S-1 for Pancreatic Cancer - Mid-Term Results].

BACKGROUND: Although surgical resection is the only curative strategy for pancreatic cancer, the prognosis of patients with pancreatic cancer remains poor. Recently, neoadjuvant treatment has been frequently employed as a promising treatment. Here, the mid-term results of neoadjuvant chemoradiotherapy(NACRT)using S-1, which has been performed in our hospital since 2008, are reported. METHODS: Seventy-nine patients with resectable or borderline resectable pancreatic ductal adenocarcinoma, who had been intended to undergo NACRT treatment using S-1, were enrolled. The NACRT comprised radiotherapy( 1.8 Gy×28 days)and full-dose twice-daily oral S-1 given on the same days as the radiotherapy. The results of the NACRT and pancreatectomy and the patients' prognoses were evaluated. RESULTS: Fifty-five patients(69.6%)underwent pancreatectomy, with no case of mortality. The curative resection rate was 94.5%. Postoperative adjuvant chemotherapy was administered in 46 patients(83.6%). The 3-year survival rates of all 79 patients and 55 pancreatectomy patients were 40.1% and 50.4%, respectively. CONCLUSION: NACRT using S-1 was found to be feasible, and good mid-term outcomes were obtained. However, analysis of the long-term outcomes and comparisons with other novel anti-cancer drugs are still required.

What are the appropriate indicators of surgical difficulty during laparoscopic cholecystectomy? Results from a Japan-Korea-Taiwan multinational survey.

BACKGROUND: Serious complications continue to occur in laparoscopic cholecystectomy (LC). The commonly used indicators of surgical difficulty such as the duration of surgery are insufficient because they are surgeon and institution dependent. We aimed to identify appropriate indicators of surgical difficulty during LC. METHODS: A total of 26 Japanese expert LC surgeons discussed using the nominal group technique (NGT) to generate a list of intraoperative findings that contribute to surgical difficulty. Thereafter, a survey was circulated to 61 experts in Japan, Korea, and Taiwan. The questionnaire addressed LC experience, surgical strategy, and perceptions of 30 intraoperative findings listed by the NGT. RESULTS: The response rate of the survey was 100%. There was a statistically significant difference among nations regarding the duration of surgery and adoption rate of safety measures and recognition of landmarks. The criteria for conversion to an open or subtotal cholecystectomy were at the discretion of each surgeon. In contrast, perceptions of the impact of 30 intraoperative findings on surgical difficulty (categorized by factors related to inflammation and additional findings of the gallbladder and other intra-abdominal factors) were consistent among surgeons. CONCLUSIONS: Intraoperative findings are objective and considered to be appropriate indicators of surgical difficulty during LC.

Successful treatment of gallbladder dyskinesia by laparascopic cholecystectomy: Report of a case.

A 75-year-old woman entered the hospital emergency room complaining of severe epigastric pain. She had experienced similar repeated abdominal pain for some time. Biliary tract dyskinesia was suspected based on the Roma III criteria. When drip infusion cholangiography-CT with egg yolk load was performed, the contraction rate of the gallbladder before and after applying the load was as low as 33.5%. Upon biliary tract scintigraphy, biliary excretion into the intestinal tract was found to be normal, but after the egg yolk load, the biliary excretion rate in the gallbladder decreased to 14.5%. Laparoscopic cholecystectomy was performed under a diagnosis of flaccid-type gallbladder dyskinesia. A few reports exist describing cases in which cholecystectomy was performed for gallbladder dyskinesia, so we are submitting this report with some bibliographic consideration.

Serum CD10 is associated with liver metastasis in colorectal cancer.

INTRODUCTION: Colorectal cancer (CRC) is the third leading cause of cancer death in Japan. CD10 expression is closely associated with liver metastasis. In the present study, we explored the possibility of serum CD10 as a marker of liver metastasis in CRC. METHODOLOGY: BALB/c mouse with subcutaneous tumor of syngeneic CT26 CRC cells were examined serum CD10. In 84 CRC patients and patients undergoing hemodialysis, serum CD10 was examined. CD10 concentration was measured by enzyme-linked immunosorbent assay. RESULTS: In a mouse subcutaneous tumor model, serum CD10 correlated with the weight of the tumors. Serum CD10 was examined in 84 patients with CRC. The serum levels of CD10 were higher in patients with more advanced cancer stages. Patients with liver metastasis showed the highest levels of serum CD10 among all patients. Importantly, patients with high serum CD10 levels had metachronous liver metastasis. Healthy volunteers showed low levels of CD10; however, serum CD10 levels in patients undergoing hemodialysis showed levels as high as those with stage II and III CRC. A cutoff of serum CD10 set to >1000 pg/mL showed 70% sensitivity and 93% specificity for liver metastasis in CRC. This cutoff included all cases of metachronous liver metastasis. CONCLUSIONS: With the exclusion of mimicking factors, serum CD10 levels might serve as a useful marker of synchronous and metachronous liver metastasis in CRC.

AKT activation and telomerase reverse transcriptase expression are concurrently associated with prognosis of gastric cancer.

AKT is a protein in the phosphatidylinositol-3 kinase (PI3K) pathway and associated with diverse pro-tumoral responses. Activation of the human telomere reverse transcriptase (hTERT) is one of AKT's tumorigenic effects. In this study, the significance of AKT phosphorylation and hTERT on prognosis of gastric cancer were examined. AKT activation by epidermal growth factor increased hTERT expression and telomerase activity. In contrast, AKT inactivation by inhibitors and knockdown decreased hTERT expression and telomerase activity in MKN28 gastric cancer cells. In 40 gastric cancer tissues, significant correlations were found among the levels of phosphorylated AKT (pAKT), hTERT expression, and telomer length. The pAKT levels or the levels of pAKT/hTERT were not associated with clinicopathological parameters, including stage and nodal metastasis. However, survival rates of the pAKT-high patients or the pAKT-high and hTERT-high patients were significantly poorer than those in other patients. These findings suggest that AKT and hTERT are good molecular targets for the treatment of gastric cancer.

Two rare metachronous metastases of hepatocellular carcinoma after liver transplantation.

A 59-year-old male with hepatocellular carcinoma (HCC) due to liver cirrhosis caused by the hepatitis C virus underwent cadaveric whole liver transplantation. Two years later, he had a metastatic HCC in the superior mediastinum. Over the following postoperative year, he underwent transcatheter arterial chemoembolization (TACE) for 4 tumors in the implanted liver. In the third post-TACE month, he was emergently hospitalized due to intracerebral hematoma with a tumor invading the bone in the medial frontal segment. He underwent emergency intracranial tumorectomy and hemorrhage removal. The histopathologic diagnosis was metastatic HCC. He regained consciousness as well as the ability to speak and to feed himself, resulting in an improved quality of life. The incidence of HCC recurrence after liver transplantation is observed in approximately 8% to 11% of selected cases, with frequent relapses observed in the implanted liver, bones, adrenal glands, and lungs. Mediastinal and intracranial metastases from HCC post-liver transplantation are very rare.

Increased phosphorylation of AKT in high-risk gastric mucosa.

AIM: To establish the role of oxidative stress and v-akt murine thymoma viral oncogene homolog (AKT) activation in gastric cancer development, we examined the levels of phosphorylated AKT (pAKT), inducible nitric oxide synthase (iNOS), nitrotyrosine (NT), and human telomerase reverse transcriptase (hTERT) by enzyme-linked immunosorbent assay in 73 non-cancerous gastric mucosa and 10 gastric carcinomas. We found that the levels of pAKT were associated with the levels of iNOS, NT, and hTERT. Gastric mucosa was classified into four categories: chronic gastritis without Helicobacter pylori (CG), chronic active gastritis with H. pylori (CAG), chronic metaplastic gastritis without H. pylori (CMG), and chronic gastritis with atypia without H. pylori (CGA). We found increasing levels of pAKT, iNOS, and NT in the order of CG, CAG, CMG, and CGA. hTERT was detected only in CGA. These findings suggest that oxidative stress might be associated with AKT activation and hTERT induction and that mucosa in CGA might confer a high-risk status for gastric carcinogenesis.

Significance of epithelial growth factor in the epithelial-mesenchymal transition of human gallbladder cancer cells.

Five gallbladder cancer (GBC) cell lines were examined for morphological changes in collagen gel culture. GBh3 and HUCCT-1 cells formed tubules in response to treatment with epithelial growth factor (EGF) and hepatocyte growth factor (HGF), and showed high levels of expression of E-cadherin (ECD), and low levels of SNAIL, vimentin, transforming growth factor (TGF)-ß, and nucleostemin (NS). In contrast, the GBd15 and FU-GBC-1 cell lines treated with EGF and HGF showed a scattering phenotype, and expressed low levels of ECD and high levels of SNAIL, vimentin, TGF-ß, and NS. All cell lines expressed the EGF receptor, c-Met, EGF, and TGF-α, but not HGF. Transforming growth factor-ß was upregulated by EGF. Knockdown of the EGF receptor abrogated both tubule formation and scattering, whereas KD of TGF-ß abrogated only scattering. Knockdown of EGF induced nuclear translocation of ß-catenin and Wnt-related NS induction in the scattering cell lines, but not in the tubule-forming cell lines, whereas KD of glycogen synthase kinase-3ß in the tubule-forming cell lines resulted in the nuclear translocation of ß-catenin and Wnt-related NS induction in response to EGF treatment. These results suggest that EGF enhances epithelial-mesenchymal transformation and acquisition of stemness in GBC cells with a scattering phenotype through the activity of ß-catenin. Repression of ECD in scattering GBC cells induced the release of ß-catenin from the cell adhesion complexes along the plasma membrane and its translocation to the nucleus to activate Wnt signaling, which upregulated NS.

The efficacy of diffusion-weighted imaging for the detection and evaluation of acute pancreatitis.

BACKGROUND/AIMS: Diffusion-weighted imaging (DWI) is a new magnetic resonance imaging (MRI) technique that evaluates the random motion of water molecules in biological tissues. The clinical utility of DWI has been established for acute stroke and brain tumors. Recent technical advancements in MRI have enabled DWI for the body and several studies have revealed the efficacy of DWI for detecting various diseases. This study documents the efficacy of DWI for the evaluation of acute pancreatitis. METHODOLOGY: MRI was performed with sequences including T1-weighted, T2-weighted, diffusion-weighted imaging, MR cholangiopancreatography (MRCP) and computed tomography (CT) examinations on 11 patients with mild acute pancreatitis. MRI examinations were performed using 1.5-T imager (Toshiba, Otawara, Japan). Two experienced radiologists evaluated the presence or absence of acute pancreatitis, complications and the cause of acute pancreatitis on the MRI and CT images. RESULTS: There were no differences between the DWI and the CT images regarding their abilities to detect acute pancreatitis. However, DWI could detect acute pancreatitis more clearly than CT without enhancing material. The DWI findings were consistent with the clinical findings, the results of chemical analyses and the CT findings. Furthermore, DWI could detect pancreatic cancer causing acute pancreatitis and MR cholangiopancreatography (MRCP) could detect choledocholithiasis and pancreas divisum causing acute pancreatitis. CONCLUSIONS: DWI can be a powerful tool for the evaluation and follow-up of acute pancreatitis.

The efficacy of diffusion-weighted imaging for the detection of colorectal cancer.

BACKGROUND/AIMS: Diffusion-weighted imaging (DWI) is a new magnetic resonance (MR) imaging technique that evaluates the diffusion of water molecules. Its clinical usefulness in the acute stage of cerebral infraction has been established. Recent technical developments have enabled DWI for human body and the usefulness of DWI for detecting malignant tumors such as liver, kidney, ovary, and breast tumors has been reported. This study documents cases of colorectal cancer detected by DWI and discusses the efficacy of DWI for the evaluation of colorectal cancer. METHODOLOGY: DWI, computed tomography (CT) and colonoscopy examinations were performed on 18 patients with colorectal cancer. MRI examinations were performed using a 1.5-T imager (Toshiba, Otawara, Japan). The signal intensity was measured in a series of DWI and the apparent diffusion coefficient (ADC) values were calculated in order to differentiate the cancers from normal tissues. Two experienced radiologists evaluated the depth of tumor invasion into the colorectal wall (tumor staging), the involvement of regional lymph nodes (nodal staging), and the presence or absence of metastasis (metastatic staging) on DWI and CT images according to the TNM classification system. TNM staging of each tumor was compared with the pathologic and surgical findings. RESULTS: There were no differences between the DWI and the CT images regarding their abilities to detect early colorectal cancer. However, DWI could detect advanced colorectal cancer and liver metastasis more sensitivity, or accurately than CT with no enhancing material. In one patient who did not undergo a surgical resection, a follow up DWI showed peritoneal seeding and bone metastasis. CONCLUSION: Although DWI has a difficulty to detect early colorectal cancer, DWI has the potential to be clinically effective for the evaluation of preoperative TNM staging and the postoperative follow-up of colorectal cancer.

Usefulness of diffusion-weighted imaging (DWI) for the detection of pancreatic cancer: 4 case reports.

The clinical utility of diffusion-weighted magnetic resonance imaging (DWI) was originally established for acute stroke; however, recent studies suggest that DWI may be more sensitive and specific for the detection and staging of malignant tumors than either computed tomography (CT) or ultrasonography (US). We herein present 4 cases of pancreatic cancer that were detected by DWI and subsequently discuss the efficacy of DWI for the diagnosis pancreatic cancer. We performed both DWI and dynamic CT examinations on 4 patients with pancreatic cancer. MR examinations were performed with a 1.5-T imager (Toshiba). We measured the signal intensity in a series of DWI images and calculated the apparent diffusion coefficient (ADC) values to differentiate the tumors from normal tissue, inflammation, or another lesion. Two radiologists analyzed the DWI and CT images, and the evaluation of the primary tumor (T), regional lymph nodes (N), and distant metastatic disease (M) was conducted according to the TMN classification system. There were no differences between the DWI and the CT images regarding their abilities to detect advanced pancreatic cancer. However, DWI displayed superior ability in detecting early stage tumors and evaluating the degree of tumor invasion. DWI has the potential to be clinically effective in the detection of early pancreatic cancer, and DWI can be a powerful tool for the evaluation of pancreatic cancer.

The usefulness of diffusion-weighted imaging (DWI) for the detection of gastric cancer.

BACKGROUND/AIMS: Diffusion-weighted imaging (DWI) is already utilized in the important clinical diagnosis of brain ischemia and also for differentiating brain abscesses from metastatic brain tumors. Recent technical developments make DWI of the body feasible. Several studies have revealed the usefulness of DWI for the diagnosis of liver, ovary, parotid gland, kidney, and breast tumors. We herein present cases of gastric cancer detected by DWI and discuss the efficacy of DWI for the diagnosis of gastric cancer. METHODOLOGY: We performed DWI, enhanced computed tomography (CT) and endoscopic examinations on 15 patients with gastric cancer. MR examinations were performed using the 1.5-T imager (Toshiba). We measured the signal intensity in a series of DWI images and calculated the apparent diffusion coefficient (ADC) values in order to differentiate the tumors from normal tissues and inflammations. Two experienced radiologists evaluated the depth of tumor invasion into the gastric wall (tumor staging), the involvement of regional lymph nodes (nodal staging), and the presence or absence of metastasis (metastatic staging) on DWI and CT images according to the TMN classification system. TMN staging of each tumor was compared with the pathologic and surgical findings. RESULTS: There were no differences between the DWI and the CT images regarding their abilities to detect advanced gastric cancer. However, DWI could detect peritoneal dissemination, liver metastasis, lymph nodes metastasis without any enhancement material more clearly than CT. CONCLUSIONS: DWI is therefore considered to have the potential to be clinically effective for the evaluation of preoperative TMN staging of gastric cancer.

Diffusion-weighted imaging is a feasible method for screening colorectal cancer: report of a case.

The liver is one of the most common sites for metastatic disease. It is sometimes difficult to detect the primary site. We describe herein the feasibility of diffusion-weighted imaging (DWI) for searching primary site of liver metastases. A 93-year-old male patient presented to us with the chief complaints of hematochezia. Ultrasonography (US) and computed tomography (CT) showed multiple masses in the liver. However, these examinations revealed no primary tumor. DWI showed bright signal mass in the rectum. Furthermore, the apparent diffusion coefficient (ADC) map in that area was depicted as a low ADC value. A histopathological analysis demonstrated the tumor to be moderately differentiated adenocarcinoma. We consider that DWI is a feasible method for screening colorectal cancer, especially for unknown primary site cancers.