Successful Treatment with 5-fluorouracil and Levofolinate Calcium in Advanced Gastric Cancer Patient with Disseminated Intravascular Coagulation.

A 32-year-old woman was found to have a gastric adenocarcinoma with multiple bone metastases. Chemotherapy in the first, second and third-line was not effective. Blood examinations showed disseminated intravascular coagulation(DIC)at the end of the second-line chemotherapy. The fourth-line chemotherapy, infusional 5-fluorouracil and levofolinate calcium was performed. This resulted in a good response for DIC. This palliative therapy was effective and safety.

High-intensity focused ultrasound treatment for hepatocellular carcinoma.

High-intensity focused ultrasound (HIFU) represents a method employing high-intensity ultrasound energy to induce thermal ablation of cancerous cells. Regarded as minimally invasive, HIFU treatment offers reduced risk of complications and abbreviated recovery periods compared to surgical interventions. Although predominantly utilized in the management of pancreatic malignancies, ongoing investigations are exploring its viability in addressing hepatocellular carcinoma. Although HIFU may be employed independently in hepatocellular carcinoma treatment, its potential as a synergistic component within combination therapies is under scrutiny. Moreover, emerging research endeavors have explored the multifaceted utility of HIFU, encompassing not only localized thermal ablation but also functionalities like drug delivery and gene therapy, augmenting its therapeutic efficacy. Despite the promising outlook of HIFU in the management of hepatocellular carcinoma, existing constraints and challenges persist. Continued research initiatives and technological innovations are anticipated to propel HIFU into a pivotal and established therapeutic modality in the foreseeable future. This article provides an overview of HIFU therapy for hepatocellular carcinoma and presents a comprehensive update on its current clinical status.

Diffusion-weighted MRI for differential diagnosis in gallbladder lesions with special reference to ADC cut-off values.

BACKGROUND/AIMS: We retrospectively evaluated the usefulness of the apparent diffusion coefficient (ADC) measured from high-b value diffusion-weighted imaging (DWI) of magnetic resonance imaging for the differential diagnosis of gallbladder lesions among patients with cancer, adenoma and inflammatory disease. METHODOLOGY: Forty patients with gallbladder lesions (22 patients with cancer, 7 patients with adenoma, and 11 patients with inflammatory disease) were enrolled in this study. All patients underwent high-b value DWI, and the ADC value was measured. The cut-off values were determined by receiver operating characteristic analysis. RESULTS: The ADC values of gallbladder cancers (1.31±0.57x10-3 mm2/s) were smallest and those of adenomas (2.66±0.43x10-3 mm2/s) were largest among the diseases. Inflammatory diseases took a middle position (1.97±0.54x10-3 mm2/s) between them. There were significant differences among the 3 groups of diseases (p<0.05). The cut-off value within ADC values to discriminate cancer from the other diseases was 1.64x10-3 mm2/s (accuracy 87.5%), and that to discriminate adenoma was 2.25x10-3 mm2/s (accuracy 90.0%). CONCLUSIONS: The ADC values measured from high-b value DWI would be useful for the differential diagnosis of gallbladder lesions.

A case of intussusception caused by cecal duplication after COVID-19.

Coronavirus disease 2019 (COVID-19) was thought to have respiratory symptoms as the main manifestation, but it has become clear that extrapulmonary symptoms such as gastrointestinal disorders also occur. There are several reports of intussusception associated with COVID-19 in children, but these are rare in adults. In this report, we present a case of cystic intestinal duplication that enlarged during the course of COVID-19 treatment and resulted in intussusception. Right hemicolectomy was performed for intussusception due to the cystic lesion. To the best of our knowledge, this is the first resected case of intussusception due to alimentary tract duplication after COVID-19 infection.

Experimental study of a physician-controlled electrocautery-enhanced delivery system incorporating a newly developed lumen-apposing metal stent for interventional endoscopic ultrasound (with videos).

BACKGROUND/PURPOSE: Although the lumen-apposing metal stent (LAMS) is useful for interventional endoscopic ultrasound (EUS) procedures, there has been some concern about the potential for stent-induced adverse events because of the high lumen-apposing force. A newly designed LAMS with less lumen-apposing force has been developed for use with a physician-controlled electrocautery-enhanced delivery system. The aim of this animal study was to evaluate the feasibility of performing interventional EUS using this newly designed LAMS system. METHODS: Endoscopic ultrasound-guided cystogastrostomy was performed using the novel LAMS three times in a wet simulation model. EUS-guided gastroenterostomy and EUS-guided gallbladder drainage were then performed using the system in four pigs. RESULTS: The LAMS was successfully placed in all three EUS-guided cystogastrostomy procedures using the wet simulation model and in all four EUS-guided gastroenterostomy and gallbladder drainage procedures in the animal model. In the 3 weeks following the procedure, eating behavior was normal in all animals and there were no adverse events. The stents remained patent during this time and were removed without difficulty. The fistula was mature in all cases and a standard upper gastrointestinal endoscope was easily advanced via the fistula to observe the afferent and efferent loops or the lumen of the gallbladder. Necropsy confirmed complete adhesion between the stomach and the wall of the jejunum or gallbladder. CONCLUSIONS: Our study findings demonstrate the feasibility of this new LAMS system and its potential clinical value for interventional EUS.

Pigmentary complication of the peristomal skin in colorectal cancer patients under systemic chemotherapy using S-1: report of cases.

PURPOSE: This study describes hyperpigmentation at the epidermis around a colostomy during and after systemic chemotherapy with S-1 (a compound of tegaful, gimestat, and potassium oxonate). SUBJECTS AND SETTING: Thirty-one colorectal cancer patients (male 17, female 14) visited the stoma-care clinic, akita university hospital between april 2003 and march 2006. fourteen patients (male 8, female 6) had been observed continuously for more than 3 months. METHODS: Results of 5 male patients who received systemic chemotherapy using S-1 were compared to those of 9 male and female patients who did not receive S-1. the shades of epidermal pigmentation at the peristomal area were graded on a 3-point likert scale, where grade 2 indicated very dark pigmentation, grade 1 indicated moderately dark pigmentation, and grade 0 indicated no pigmentation of the peristomal skin. RESULTS: Pigmentation scores in patients receiving S-1 were significantly higher than scores in patients who did not receive S-1 systemic chemotherapy. CONCLUSIONS: Rapid and excessive pigmentation of the peristomal skin may occur in patients receiving S-1 systemic chemotherapy because it indicates an adverse event related with systemic chemotherapy and leads to peristomal skin problems.

Morphological study of the gastrointestinal tract around the ligament of Treitz using upper gastrointestinal radiography: Fundamental data for EUS-guided gastrojejunostomy.

BACKGROUND/PURPOSE: We developed EUS-guided double-balloon occluded gastrojejunostomy (EPASS) for gastric drainage tract obstruction. The success of EPASS depends on the proximity of the stomach and the gastrointestinal (GI) tract near the ligament of Treitz. The aim of this study is to clarify the GI anatomy near the ligament of Treitz. METHODS: One thousand and sixteen cases imaged upper GI radiography using barium were retrospectively evaluated. Morphologically, the GI tract running near the ligament of Treitz was divided in three types: Type I: The 4th portion of the duodenum (D4) approaches the stomach; Type II: D4 does not approach the stomach; Type III: D4 forms a loop to the jejunum. The minimum distance between the stomach and the GI tract near the ligament of Treitz was measured. RESULTS: Based on the morphological classification, 74.6% in the study group was classified in Type I, 22.0% in Type II, and 3.3% in Type III, respectively. The median minimum distance in Type II/III group were significantly longer, compared with the Type I (P < .01). CONCLUSIONS: The GI anatomy near the ligament of Treitz was clarified using upper GI radiography. It is divided into three patterns, and one-fourth of cases may have difficulty in EUS-guided gastrojejunostomy.

Novel Therapeutic Method for Unresectable Pancreatic Cancer-The Impact of the Long-Term Research in Therapeutic Effect of High-Intensity Focused Ultrasound (HIFU) Therapy.

High-intensity focused ultrasound (HIFU) is a novel advanced therapy for unresectable pancreatic cancer (PC). HIFU therapy with chemotherapy is being promoted as a novel method to control local advancement by tumor ablation. We evaluated the therapeutic effects of HIFU therapy in locally advanced and metastatic PC. PC patients were treated with HIFU as an optional local therapy and systemic chemotherapy. The FEP-BY02 (Yuande Bio-Medical Engineering) HIFU device was used under ultrasound guidance. Of 176 PC patients, 89 cases were Stage III and 87 were Stage IV. The rate of complete tumor ablation was 90.3%, while that of symptom relief was 66.7%. The effectiveness on the primary lesions were as follows: complete response (CR): n = 0, partial response (PR): n = 21, stable disease (SD): n = 106, and progressive disease (PD): n = 49; the primary disease control rate was 72.2%. Eight patients underwent surgery. The median survival time (MST) after diagnosis for HIFU with chemotherapy compared to chemotherapy alone (100 patients in our hospital) was 648 vs. 288 days (p < 0.001). Compared with chemotherapy alone, the combination of HIFU therapy and chemotherapy demonstrated significant prolongation of prognosis. This study suggests that HIFU therapy has the potential to be a novel combination therapy for unresectable PC.

A case of gastric cancer with delayed onset of tumor reduction effect by nivolumab therapy.

Immune checkpoint inhibitors may have different clinical effects compared with conventional anticancer drugs. An 85-year-old male received chemotherapy for recurrent gastric cancer. As liver metastasis progressed, nivolumab was introduced as a fourth line treatment. Progression of liver metastasis in size was observed in CT after 3 courses of nivolumab therapy. Nivolumab treatment was discontinued, because the general condition of the patient also worsened. However, his general condition improved as hepatobiliary enzyme levels, inflammatory response, and tumor markers improved. Liver metastasis was shrinking on the image, so we resumed nivolumab therapy. To the authors' knowledge, this is the first case of pseudoprogression undergoing immunotherapy for gastric cancer. In this case, the antitumor effect was exhibited in a delayed manner and the tumor shrinkage was obtained.

A newly designed magnet-retracting forceps for laparoscopic cholecystectomy in a swine model.

We designed a method for remote-controlled endoscopic surgery using magnet-retracting forceps. To evaluate the feasibility of this technique, laparoscopic cholecystectomy was attempted in a swine model. This method takes advantage of the attractive force between two magnets, one inserted into the peritoneal cavity and the other located outside the abdominal wall. An intra-peritoneal magnet was fixed to the fundus of the gallbladder using an endovascular clip. Laparoscopic cholecystectomy was accomplished by magnetic retraction of the gallbladder. This magnet-retracting forceps provided port-less access to the abdominal cavity. Since the direction and range of retraction were unrestricted by the location of access-ports fixed on the abdominal wall, surgery could be less invasive. In addition, this procedure provided surgeons with excellent endoscopic views, as retraction force was supplied without any shaft device in the abdomen. This operation system using magnetic retraction appears promising.

Superb microvascular imaging (SMI) findings of splenic artery pseudoaneurysm: a report of two cases.

Splenic artery pseudoaneurysm (SAPA) is a relatively infrequently encountered but clinically important vascular change, because it carries a high risk of rupture that warrants prompt treatment regardless of its size. Thus, sufficient knowledge is indispensable when seeing chronic pancreatitis patients or post-traumatic patients. Here, we report two such cases. The first case was a 52-year-old woman known to have chronic pancreatitis who presented with hematemesis and hemodynamic instability in which X-ray computed tomography (CT) and color Doppler sonography (CDS) had difficulty visualizing slow blood flow in SAPA, but superb microvascular imaging (SMI) clearly demonstrated the slow blood flow in SAPA, prompting our therapeutic decision to perform rapid embolization. The second case was a 51-year-old woman with post-traumatic SAPA in which 3D SMI enabled us to understand more clearly the topographic relationship between multiple SAPAs as compared with conventional US, leading to a decision to provide immediate surgical treatment. SMI was thought to provide a new insight into the US diagnosis of SAPA. When examining patients suspected of having a SAPA, SMI is an indispensable diagnostic tool at present.

Stent placement is effective on both postoperative hepatic arterial pseudoaneurysm and subsequent portal vein stricture: a case report.

To treat postoperative bleeding after hepato-pancreato-biliary surgery, interventional radiology has become essential. We report a case of coincidental pseudoaneurysm and jejunal varices that were both successfully treated by stent-grafts. After a pancreaticoduodenectomy, the patient developed a pseudoaneurysm in the hepatic artery and a stenosis in its periphery. After establishing hepatic arterial flow by placing stent-grafts over both the pseudoaneurysm and the stenosis, the pseudoaneurysm was embolized with microcoils. Nine months later, the patient developed jejunal varices caused by a severe stricture in the main trunk of the portal vein. Percutaneous transhepatic portography was performed and stent-grafts were placed over the stenotic segment. A venoplasty using stent-grafts normalized the portal blood flow and the jejunal varices vanished. Although stenosis occurred due to scarred tissues from leakage after pancreaticoduodenectomy, stent-grafts were useful for managing jejunal bleeding post-operatively.

Domino Reconstruction of the Portal Vein Using the External Iliac Vein and an ePTFE Graft in Pancreatic Surgery.

BACKGROUND: In the portal vein resection of long distance, an interposition by autologous vein is mandatory. External iliac vein (EIV) has been used, but harvesting the EIV is associated with severe venous congestion of the affected lower extremity. We have reconstructed the EIV using a ringed expanded polytetrafluoroethylene (ePTFE) graft. METHODS: Thirteen patients underwent this surgery. The right EIV was used for reconstructing the portal vein, and the retrieved portion of EIV was interposed by the ePTFE graft. We evaluated size and length of the graft, graft patency, girth of thigh, time for reconstruction of EIV, and graft infection. RESULTS: ePTFE grafts of 8 or 10 mm in diameter were used. The length of ePTFE graft used was 4.4 ± 0.5 cm. Graft patency was kept in 76.9% patients. Graft obstruction was encountered in three patients, and the girth of right thigh increased by about 10 cm. Time for reconstruction of EIV was 29.5 ± 6.8 min. Graft infection did not occur in any patients. CONCLUSIONS: Reconstruction of the EIV using a ringed ePTFE graft seems to be a feasible option for preventing the swelling of the affected lower extremity after procurement of EIV for repairing the portal vein.

The transformation of a nonfunctioning islet cell tumor of the pancreas into a proinsulinoma under conditions of lung metastasis.

We herein report the first case of a nonfunctioning islet cell tumor that transformed into a proinsulinoma during the process of metastasis to the lungs. This phenomenon was confirmed in a 69-year-old woman with an advanced pancreatic islet cell tumor and multiple liver metastases who later developed multiple lung metastases. She underwent pancreatic resection followed by the administration of chemotherapy and survived for seven years. Although the patient initially had hyperglycemia due to diabetes mellitus, she conversely began to manifest hypoglycemic attacks 63 months postoperatively with the concomitant development of multiple lung metastases. An autopsy revealed that only the tumor in the lungs produced proinsulin; no other hormones were detected.

Mesenteric lymph node abscess due to Yersinia enterocolitica: case report and review of the literature.

We describe the case of a 74-year-old female with a mesenteric lymph node abscess caused by a Yersinia enterocolitica infection. She had been administered an immunosuppressive drug and was admitted to the hospital due to a high fever, right lower abdominal pain and advanced leukocytosis. We initially diagnosed her with lymphadenitis based on the symptoms and the imaging studies. However, conservative treatment with antibiotics did not yield any improvement, and abscess formation was suspected. Surgical treatment was performed, and the culture from the drainage fluid grew Y. enterocolitica. The histological findings suggested that an ulcerative lesion of the terminal ileum was the entry port of Y. enterocolitica. The pathogen infected the mesenteric lymph nodes and spread along the ileocecal lymphatic vessels, resulting in the formation of an abscess. We also provide a review of the previously published literature on lymph node abscesses due to Y. enterocolitica infections.

Acquired/intratumoral mutation of KRAS during metastatic progression of colorectal carcinogenesis.

Mutations at codons 12 and 13 of the KRAS gene have been identified as level I predictive biomarkers against the treatment of advanced colorectal cancer with anti-epidermal growth factor receptor (EGFR) monoclonal antibodies. It is thought that the genetic analysis of KRAS mutations associated with metastatic colorectal cancer can be routinely conducted using DNA obtained on one occasion from one organ, from the primary or a metastatic site, whichever is preferentially available. However, the issue of tumor heterogeneity resulting from acquired/intratumoral mutations remains. Recently, the possibility of acquired/intratumoral mutations in the KRAS gene has been reported by two research groups and has ranged from 7.4 to 15.4%. Specimens were collected from advanced colorectal cancer patients with resected primary, and at least one metastatic, site. Direct sequence analysis was performed for KRAS, BRAF and PIK3CA, and immunohistochemistry for glutathione S-transferase II (GSTP) and EGFR. In the current study, we identified an acquired mutation rate of approximately 11.1% in the KRAS gene (1/9). This figure is not negligible. Our observation indicates, particularly in the case of metastatic recurrence after a long interval, that there may be considerable tumor heterogeneity resulting from acquired or intratumoral mutations of the KRAS gene.

(18)FDG-PET at 1-Month Intervals Is a Better Predictive Marker for GISTs That Are Difficult to Be Diagnosed Histopathologically: A Case Report.

Imatinib mesylate is a tyrosine kinase inhibitor of c-KIT and PDGFRA. Imatinib mesylate is an effective drug that can be used as a first-choice agent for treatment of GISTs. Prior to treatment, molecular diagnosis of c-KIT or PDGFRA is necessary; however, in some types of GISTs, it is impossible to obtain a sufficient amount of specimen for diagnosis. An inoperable or marginally resectable GIST in a 79-year-old female was difficult to be diagnosed at a molecular pathological level, and hence, exploratory treatment was initiated using imatinib combined with (18)FDG-PET evaluation at 1-month intervals. PET imaging indicated a positive response, and so we continued imatinib treatment in an NAC setting for 4 months. As a result, curative resection of the entire tumor was successfully performed with organ preservation and minimally invasive surgery. (18)FDG-PET evaluation at 1-month intervals is beneficial for GISTs that are difficult to be diagnosed histopathologically.

Acute respiratory distress syndrome associated with severe ulcerative colitis.

Various extraintestinal manifestations including pulmonary abnormalities have been reported in patients with ulcerative colitis. Acute respiratory distress syndrome (ARDS) is a serious and fatal pulmonary manifestation. We have experienced a 67-year-old male patient with ARDS associated with a severe type of ulcerative colitis (UC). Severe dyspnea symptoms occurred during the treatment of UC in a previous hospital and the patient was transferred to our hospital on June 27, 2007. Both blood and sputa cultures for bacteria and fungi were negative. Cytomegalovirus antigenemia was also not detected. From the clinical and radiological [Chest X-ray, computed tomography (CT)] findings, the patient was diagnosed with ARDS on the basis of the definition of ARDS developed by the European-American Consensus Conference on ARDS. Both colonic inflammations and ARDS symptoms of the patient were resistant to any medical treatment including corticosteroids and antibiotics. However, ARDS symptoms were dramatically improved after surgical colectomy. We believe that severe colonic inflammation from UC was closely associated with the onset of ARDS of the patient. Our case report suggests that a severe type of ulcerative colitis might be taken into consideration as one of the predisposing factors of ARDS.

Epstein-Barr virus-positive inflammatory pseudotumor of the spleen managed with laparoscopic splenectomy.

We report a case of Epstein-Barr virus (EBV)-positive splenic inflammatory pseudotumor treated by laparoscopic splenectomy. A 66-year-old female without symptoms was found to have a solitary, avascular, solid tumor of the spleen by contrast-enhanced computed tomography. The tumor was compatible with a primary tumor of the spleen. A benign splenic tumor was the most likely diagnosis, but malignant lymphoma could not be ruled out because the serum-soluble interleukin-2 receptor (sIL-2R) level was elevated. Laparoscopic splenectomy was performed to enable a definite diagnosis. Removal of the whole spleen without injury was possible. Possible contamination of the extirpation orifice by cancer cells was carefully prevented by enclosing the spleen in a plastic bag. Histopathological examination showed the tumor to be an EBV-positive inflammatory pseudotumor. To the best of our knowledge, this is only the second report of an EBV-positive splenic inflammatory pseudotumor with an increased serum sIL-2R level. Although EBV-positive inflammatory pseudotumors have been reported to recur, no sign of recurrence has been detected in the present case in the 17 months following splenectomy.

The use of magnetic anchors in the bowel lumen for laparoscopic anterior resection of rectosigmoid colon in pigs: with video.

BACKGROUND: This article describes a new technique for retracting the rectum upward during laparoscopic surgery using the pulling force created between two magnets. METHODS: A magnet and a colonoscope were inserted into the rectal cavity of a swine model, and a second magnet was placed on the abdominal wall creating a magnetic anchor or retraction that pulled the rectum upward. Subsequently, a laparoscopic anterior resection of the rectosigmoid colon was performed. The magnetic anchor transferred an electromagnetic force through the abdominal wall, creating effective organ retraction without the need of a trocar. RESULTS: Surgery without the use of trocars allows for increased flexibility in the angle, distance, and location of the retraction. Since retraction was achieved without a shaft device that can impede visibility within the abdominal cavity, the surgeons achieved excellent endoscopic views. Because the intraluminal magnetic anchor was placed directly on the inside wall of the target organ, tracking target organ movement closely with the movement of the extracorporeal control magnet was possible and synchronizing their movements was not difficult. CONCLUSION: The technique presented in this article might be less invasive and could provide more effective manageability for laparoscopic surgery.