[Percutaneous transthoracic needle biopsies under a guide of real-time three image computed tomography].

PURPOSES: Experiences of percutaneous transthoracic needle biopsies under a guide of a real time 3 image display computed tomography (3 image CT) is reported. MATERIALS AND METHODS: Twenty seven biopsies from 23 patients were performed. For 3 image CT, Somatom was used. This equipment can render 3 pictures of serial slices on a screen simultaneously and have X-ray exploration-reduction system for both the patients (35% reduction) and operator's hands (72% reduction). RESULTS: The median size of the masses was 1.7 (0.5-6.3) cm; the median distance from the pleura to the mass was 0.66 (0-6.5) cm; and the median time to perform biopsies was 12 minutes. We had only 3 failed cases to obtain biopsied specimen (11%). COMPLICATIONS: Needle biopsy of the lung lesion under a guide of a 3 sectional CT is a safe and timesaving method with a high success rate to obtain biopsied tissues even for small lesions or difficult lesion.

A case with synchronous multiple liver metastases from gastric carcinoma: postoperative long-term disease-free survival.

PURPOSE: We herein report a case with synchronous multiple liver metastases from gastric carcinoma surviving disease-free for more than 10 years after hepatic resection. METHODS: A 64-year-old male admitted to our hospital because of constitutional wariness. Preoperative diagnosis was type 1 gastric cancer at the lower third of the stomach and multiple metastases of both hepatic lobes. After we performed distal gastrectomy with regional lymphadenectomy and wedge hepatic resection for eight metastatic liver tumors, he received 5-fluoropyrimidine and platinum-based adjuvant chemotherapy during the early postoperative period. RESULTS: The pathologic examination revealed moderately differentiated gastric adenocarcinoma with regional lymph node metastasis and multiple liver metastases. The postoperative course was uneventful and the patient is doing well without disease recurrence after more than 10 years following surgery. CONCLUSION: To the best of our knowledge, this patient is the longest disease-free survivor after liver resection for synchronous multiple liver metastases from advanced gastric cancer. In this modern era of developing liver surgery and adjuvant chemotherapy, combination therapy of aggressive surgery and early postoperative adjuvant chemotherapy for advanced gastric cancer with liver metastasis may allow long-term survival in selected patients.

Serum pepsinogen levels, Helicobacter pylori CagA Status, and cytokine gene polymorphisms associated with gastric premalignant lesions in Costa Rica.

The detection of gastric premalignant lesions, atrophic gastritis, corpus atrophic gastritis, and intestinal metaplasia, using several potential markers was examined in Costa Rica. Depending on the lesion investigated, from a total of 223 dyspeptic patients, 58 (26.0%), 31 (13.9%), or 23 (10.3%) were histologically diagnosed with atrophic gastritis, corpus atrophic gastritis, or intestinal metaplasia, respectively. Sera were used for the measurement of pepsinogen (PG) and Helicobacter pylori CagA antibody (CagA-ab) levels by ELISA, and human genomic DNAs were used for the genotyping of interleukin (IL)-1beta (-511 and +3954), IL-10 (-1082 and -592), and IL-1RN intron 2 by PCR and RFLP. Multivariate analysis was done adjusting for sex, age, and H. pylori seropositivity. Low PG levels (L-PG; PG I < or = 70 microg/L + PG I/II < or = 3), very low PG levels (VL-PG; PG I < or = 30 microg/L + PG I/II < or = 2), and CagA-ab were individually associated with all premalignant lesions whereas IL-1beta +3954T-carrier and IL-1RN homozygous 2 allele were associated with intestinal metaplasia. VL-PG, for corpus atrophic gastritis detection, was the single marker with the highest combination of test characteristics, sensitivity (77.4%), specificity (80.7%), positive predictive value (39.3%), negative predictive value (95.7%), and seropositivity rate (27.4%), expected to improve after periodic measurements. Combined examinations of VL-PG and CagA-ab improved the specificity (92.7%) and positive predictive value (62.2%), with similar sensitivity (74.2%) and negative predictive value (95.7%). In conclusion, corpus atrophic gastritis detection with periodic measurements of serum PG, alone or in combination with CagA-ab status, to identify high gastric cancer risk, seems to be the method best suited for mass screening in Costa Rica.

Effects of geldanamycin and thalidomide on the Th1/Th2 cytokine balance in mice subjected to operative trauma.

BACKGROUND: Persistence of postoperative immune dysfunction is a critical problem because it increases the risk of serious infectious complications. The mechanisms of the immune dysfunction that occur initially after non-thermal operative injury remain to be fully elucidated. METHODS: Two mouse models of operative trauma (simple laparotomy to represent minor operative injury and ileocecal resection to represent major operative injury) were used to define the characteristics of initial cytokine synthesis. Geldanamycin and thalidomide were independently added intraperitoneally before and after operative injury to examine the effect on postoperative immune dysfunction. Mice were sacrificed at scheduled times (3, 6, 12, and 24 h after operative injury) and TNF-alpha, IL-2, IL-4, and IL-10 were analyzed. Spleen was used for intracellular cytokines and RT-PCR. Sera were used for ELISA. RESULTS: Major operative injury caused an initial upregulation of IL-10 synthesis with delayed synthesis of TNF-alpha and IL-2. Minor operative injury caused an early induction of IL-2 synthesis preceded by an initial induction of IL-4 synthesis. GA caused a specific early upregulation of TNF-alpha mRNA expression and intracellular TNF-alpha synthesis. The GA and THD groups showed early serum IL-2 production with reduction of IL-10 mRNA expression and intracellular IL-10 synthesis in the early post-operative phase. CONCLUSIONS: Major and minor operative injury showed different Th1/Th2 cytokine patterns in the initial post-operative period. Geldanamycin and thalidomide improved the Th1/Th2 imbalance independently after major operative injury.

Anti-reflux pouch-esophagostomy after proximal gastrectomy with jejunal pouch interposition reconstruction.

Reflux esophagitis is a serious postoperative complication for patients undergoing gastrectomy. We designed a new jejunal pouch-esophagostomy to prevent reflux after proximal gastrectomy. After proximal gastrectomy, ajejunal segment about 17 cm long was folded. Side-to-side jejuno-jejunostomy was made using a linear stapler with 100-mm staples along the length at the anti-mesenteric side. A 10-cm-longjejunal pouch with a 7-cm-long apical bridge was made. Esophago-jejuno end-to-side anastomosis (pouch-esophagostomy) was made with circular stapler at the right anterior wall the apical bridge. We add "partial posterior fundoplication" like wrapping using the apical bridge of the jejunal pouch. Patients with this new anti-reflux anastomosis showed no reflux on barium meal study even in the right anterior oblique deep Trendelenburg's position. Jejunal pouch reconstruction with partial posterior wrapping provides a satisfactory result with regard to preventing reflux esophagitis.

Hepatectomy for hepatocellular carcinoma with indocyanine green excretory defect: a case report.

A 69-year-old female patient with an indocyanine green (ICG) excretory defect underwent hepatectomy for hepatocellular carcinoma (HCC). Abdominal computed tomography confirmed a mass lesion with central necrosis in the right anterior segment of the liver. Angiography revealed tumor stain pooling and a portal venous or arterial venous shunt. The patient was carefully evaluated and then treated by surgical resection for HCC. The pathologic examination revealed moderately differentiated HCC. Her postoperative course was uneventful. ICG excretory defect did not seem to have effect on the short-term prognosis of hepatectomy.

Xanthogranulomatous pancreatic abscess secondary to acute pancreatitis: two case reports.

Xanthogranuloma is a rare type of inflammation and very few cases have been reported in the pancreas. We report two cases with xanthogranulomatous pancreatic abscess that followed acute pancreatitis. In both cases, multiple pseudocysts in the pancreatic tail were infected with several species of bacteria and Candida albicans. In one case, abdominal angiography revealed a hypoperfused pancreatic tail due to prior atherosclerotic obliteration of the celiac and superior mesenteric arteries. In the other case, the splenic artery was completely occluded by a transarterial embolization performed to treat an aneurysm that appeared in the course of pancreatitis. In both cases, distal pancreatectomy was performed as inflammation of the pancreatic tail was resistant to conventional antibiotic therapy, and pathologic examination revealed xanthogranulomatous inflammation around the pancreatic tail and spleen. Although the underlying pathogenesis is unclear, the prolonged infection and/or relative hypoxia induced by hypoperfusion are likely causative factors for the xanthogranulomatous changes in these pancreatic abscesses.

[Case of multiple (at least 28 lesions) gastric intramural metastases from gastric cancer].

A 76-year-old man was admitted for treatment of gastric cancer that causing anorexia. Endoscopy showed the stenosis in the antrum of the stomach and multiple small nodules with erosion from the upper body to the corpus of the stomach. Total gastrectomy with Roux-en-Y reconstruction was performed. On the resected specimen, there were at least 28 nodules with erosion in the submucosal layer of the entire stomach. The lesions had no continuity with one another and were the same histological type, poorly differentiated adenocarcinoma. We diagnosed these lesions as intramural metastases of gastric cancer.

Helicobacter pylori CagA status associated with gastric cancer incidence rate variability in Costa Rican regions.

BACKGROUND: We evaluated several risk factors for gastric cancer in Costa Rican regions having contrasting gastric cancer incidence rates, despite the small dimensions of the country. METHODS: A total of 180 dyspeptic patients were classified into two groups according to the gastric cancer incidence (GCI) rate in their Costa Rican region: group A, with a high GCI rate (n = 91) and group B, with a low GCI rate (n = 89). Helicobacter pylori infection was detected by rapid urease test, Gram staining, and histological observation. Antral and corpus specimens were obtained to assess the grade of inflammation, topography of gastritis, gastric atrophy, and intestinal metaplasia by histological examination. Serum CagA antibody was measured by an antigen-specific enzyme-linked immunosorbent assay. RESULTS: There was no significant difference in H. pylori prevalence between groups A (73%) and B (63%); however, serum CagA antibody was more frequently detected in group A (79%) than in group B (54%) [P = 0.02; odds ratio (OR), 2.68]. Among patients under 60 years of age, serum CagA antibody was even more frequently detected in group A (81%) than in group B (49%) (P < 0.01; OR, 4.50). The prevalence of corpus-predominant gastritis, atrophic gastritis, and moderate/severe grades of neutrophilic infiltration was higher in serum CagA antibody-positive patients than in CagA antibody-negative patients (P = 0.003, 0.04, and 0.002, respectively). CONCLUSIONS: Infection with H. pylori possessing the cagA gene is associated with the development of severe gastric damage such as gastric atrophy, leading to gastric cancer, and probably influences the differences in GCI between Costa Rican regions.

A simple biangulation stapling technique for large anastomoses in gastric surgery.

We describe here a new technique for performing the large anastomosis between the jejunal pouch and the remnant stomach in patients undergoing proximal gastrectomy with jejunal pouch interposition. The biangulation method described in this report is a simpler technique than the existing triangulation anastomosis technique, requiring only two applications of a linear stapler. One row of staples forms the posterior wall of the anastomosis and the other forms the anterior wall. When used for jejunal pouch reconstruction after proximal gastrectomy in 12 cases of early gastric cancer, no evidence of anastomotic leakage or stenosis was apparent from barium meal studies or endoscopic examination. We find this biangulation technique to be a simple and safe procedure that is ideal for anastomoses of large diameter.

STI571 (Glivec) induces cell death in the gastrointestinal stromal tumor cell line, GIST-T1, via endoplasmic reticulum stress response.

STI571 is a specific inhibitor of tyrosine kinases, such as BCR-ABL, platelet-derived growth factor receptor, and c-KIT, and has recently been approved for the treatment of chronic myeloid leukemia and gastrointestinal stromal tumors (GISTs). This study demonstrated that STI571 induces cell death in the gastrointestinal stromal tumor cell line, GIST-T1. In these cells, STI571 induced pro-caspase-12 or pro-caspase-7 cleavage and it affected caspase-3 activity and induced the endoplasmic reticulum (ER)-resident chaperone, glucose-regulated protein 78. The STI571-induced cell death was blocked by the protein synthesis inhibitor, cycloheximide. Together, these results suggest that STI571 induces cell death in GIST-T1 cells, at least in part, via the ER stress response.

Preoperative assessment of vascular anatomy of inferior mesenteric artery by volume-rendered 3D-CT for laparoscopic lymph node dissection with left colic artery preservation in lower sigmoid and rectal cancer.

AIM: To determine the distance between the branching point of the left colic artery (LCA) and the inferior mesenteric artery (IMA) by computed tomography (CT) scanning, for preoperative evaluation before laparoscopic colorectal operation. METHODS: From February 2004 to May 2005, 100 patients (63 men, 37 women) underwent angiography performed with a 16-scanner multi-detector row CT unit (Toshiba, Aquilion 16). All images were analyzed on a workstation (AZE Ltd, Virtual Place Advance 300). The distance from the root of the IMA to the bifurcation of the LCA was measured by curved multi-planar reconstruction on a workstation. RESULTS: The IMA could be visualized in all the cases, but the LCA was missing in two patients. The mean distance from the root of the IMA to the root of the LCA was 42.0 mm (range, 23.2-75.0 mm). There were no differences in gender, arterial branching types, body weight, height, and body mass index. CONCLUSION: Volume-rendered 3D-CT is helpful to assess the vascular branching anatomy for laparoscopic surgery.

Pharmacokinetic study of paclitaxel in malignant ascites from advanced gastric cancer patients.

AIM: To examine the paclitaxel concentrations in plasma and ascites after its intravenous administration in patients with ascites due to peritonitis carcinomatosa resulting from advanced gastric cancer. METHODS: Two patients with ascites due to peritonitis carcinomatosa resulting from gastric cancer were included in this study. The paclitaxel concentrations in plasma and ascites were investigated for 72 h in case 1 and 168 h in case 2 after intravenous administration. RESULTS: The paclitaxel concentration in plasma peaked immediately after administration, followed by rapid decrease below the threshold value of 0.1 micromol (85 ng/mL) within 24 h. In contrast,the paclitaxel concentration in ascites increased gradually for 24 h after administration to a level consistent with the level found in plasma. After 24 h the level of paclitaxel in ascites and plasma became similar, with the optimal level being maintained up to 72 h following administration. CONCLUSION: The concentration of paclitaxel in ascites is maintained within the optimal level for the treatment of cancer cells for up to 72 h after intravenous administration. Paclitaxel is a promising drug for the treatment of malignant ascites of gastric cancer.

STI571 (Glivec) suppresses the expression of vascular endothelial growth factor in the gastrointestinal stromal tumor cell line, GIST-T1.

AIM: To estimate whether STI571 inhibits the expression of vascular endothelial growth factor (VEGF) in the gastrointestinal stromal tumor (GIST) cells. METHODS: We used GIST cell line, GIST-T1. It has a heterogenic 57-bp deletion in exon 11 to produce a mutated c-KIT, which results in constitutive activation of c-KIT. Cells were treated with/without STI571 or stem cell factor (SCF). Transcription and expression of VEGF were determined by RT-PCR and flow cytometry or Western blotting, respectively. Activated c-KIT was estimated by immunoprecipitation analysis. Cell viability was determined by MTT assay. RESULTS: Activation of c-KIT was inhibited by STI571 treatment. VEGF was suppressed at both the transcriptional and translational levels in a temporal and dose-dependent manner by STI571. SCF upregulated the expression of VEGF and it was inhibited by STI571. STI571 also reduced the cell viability of the GIST-T1 cells, as determined by MTT assay. CONCLUSION: Activation of c-KIT in the GIST-T1 regulated the expression of VEGF and it was inhibited by STI571. STI571 has antitumor effects on the GIST cells with respect to not only the inhibition of cell growth, but also the suppression of VEGF expression.

Benefits of early postoperative jejunal feeding in patients undergoing duodenohemipancreatectomy.

AIM: To study whether early postoperative enteral nutrition reduces the incidence of complications and/or improves nutritional status following duodenohemipancreatectomy (DHP). METHODS: We studied 39 patients who underwent DHP for a peri-ampullary mass. Twenty-three patients received total parental nutrition and then started to have an oral intake of nutrition between postoperative day (POD) 7 and 14 [late postoperative enteral nutrition (LPEN) group]. Sixteen patients started to have enteral feeding through a jejunostomy catheter the day after the operation [early postoperative enteral nutrition (EPEN) group]. The incidence of complications and laboratory data at the early postoperative stage were studied in comparison between LPEN and EPEN groups. RESULTS: Serum levels of albumin and total protein in the EPEN group were significantly higher than those in the LPEN group. The loss of body mass index was significantly suppressed in the EPEN group as compared to the LPEN group. The lymphocyte count decreased immediately after the operation was restored significantly faster in the EPEN group than in the LPEN group. The EPEN group showed significantly fewer incidences of postoperative pancreatic fistulas, as well as a significantly shorter length of hospitalization than the LPEN group. There were no significant differences in the incidences of other postoperative complications between the two groups, such as delayed gastric emptying, surgical site infection, cholangitis, and small bowel obstruction. CONCLUSION: EPEN is a safe and beneficial opportunity for patients who have undergone DHP for a peri-ampullary mass.

Autopsy study of anatomical features of the posterior gastric artery for surgical contribution.

AIM: To investigate features of the posterior gastric artery (PGA) with respect to incidence, location and size by using autopsy subjects. METHODS: Autopsies were performed on 72 cadavers of adults with no history of abdominal operations. The localization of the PGA, the distance between the root of the splenic artery and the origin of the PGA, and the external diameter of the PGA were examined. RESULTS: The PGA was recognized in all patients. In 70 (97.2%) cadavers, the PGA branched from the splenic artery, and one female in this group had two PGAs. In 1 (1.4%) patient, the PGA originated from the root of the celiac trunk and in another (1.4%) patient, the PGA branched from the superior polar artery. Overall, the PGA extended for a length of 5.8-12.2 (mean, 8.4) cm from the root of the splenic artery, and the external diameter of the PGA was 1.2-3.2 (mean, 2) mm. CONCLUSION: The anatomical features of the PGA can be readily observed and characterized by autopsy. This study has provided valuable information on the features of the PGA useful in the planning of surgical treatment.

Rapid growth of mucinous cystic adenoma of the pancreas following pregnancy.

A 25-yr-old woman delivered a healthy child by cesarean section. At 8 mo postpartum, she became aware of an upper abdominal tumor. Abdominal computed tomography and upper abdominal ultrasonography revealed a large cystic mass in the body of the pancreas. Endoscopic retrograde pancreatography showed no connection between the main pancreatic duct and the cystic lesion. The patient underwent tumor resection at 11 mo postpartum. Pathological examination of the tumor revealed mucin-producing columnar epithelial cells lining the cystic wall with ovarian-type stromal tissue and no findings indicative of malignancy, giving a diagnosis of mucinous cystic adenoma of the pancreas. Immunohistochemical studies revealed positive staining for progesterone receptor but not for estrogen receptor in the stromal cell nuclei. Postpartum rapid growth of a benign mucinous cystic neoplasm might be linked to the production of female sex hormones during lactation.

Clinicopathological features of type 1 gastric carcinoma: the need to be cautious of superficial lesion surrounding type 1 gastric carcinoma.

BACKGROUND/AIMS: Gastric carcinoma (GC) is one of the most common malignant tumors of the digestive tract and the incidence of adenocarcinoma of the upper one-third of the stomach has increased recently worldwide. The objective of this study was to analyze the clinicopathological variables in patients with GC and examine preoperative diagnosis and the medical treatment strategy of Type 1 GC. METHODOLOGY: Nine hundred and eighty-one patients with GC who underwent surgical resection between 1981 and 2002 at Kochi Medical School were studied. Thirty-five patients with Type 1 GC were compared with non-Type 1 GC patients on postoperative surgicopathological parameters, and changing trends were evaluated. RESULTS: The characteristics of patients with Type 1 GC were different from those of patients with non-Type 1 GC: Their tumors were more often in the upper one-third of the stomach (37% vs. 15%), lesions were histologically differentiated in 80% (vs. 56%), and there were more superficial lesions surrounding Type 1 GC (80% vs. 8%). The absolute value and the rate of Type 1 GC increased significantly from the first half to the second half of the study. CONCLUSIONS: Our findings showed that when Type 1 GC is discovered, physicians should investigate the mucosa around the main neoplasm carefully. The current series suggested that Type 1 GC are associated frequently with superficial lesions, making local resections more difficult, and that Type 1 GC was similar clinicopathologically to carcinoma of the gastric cardia and had different etiologies contributed to its tumorgenesis, compared with non-Type 1 GC, and Type 1 GC may become the key which solves the problem of carcinoma at the gastric cardia.

Management of intra-abdominal abscess due to surgical site infection.

Intra-abdominal abscesses are one of the major complications that occur after Gastrointestinal Surgery. Therapeutic modalities include drainage and irrigation. This study describes the development of a new drainage and continuous irrigation system that results in less skin irritation and reduced dressing changes. This system involved the use of the Surgidrain open top (ALCARE, Tokyo, Japan), which consists of a sealing sheet with a drainage lumen and plastic cap. A double-lumen tube was inserted into the abscess cavity through a slit in the plastic cap. The abscess cavity could, therefore, be irrigated continuously through one lumen of the double-lumen tube, and most of the fluid could be drained through the second lumen of the double-lumen tube. Overflow fluid was drained through the Surgidrain open top drainage lumen. This system enabled better protection against skin complications and the ability to easily flush the abscess intermittently.

Adenosquamous carcinoma of the extrahepatic biliary tract: clinicopathological analysis of Japanese cases of this uncommon disease.

BACKGROUND: We analyzed the clinicopathologic variables and postoperative outcomes in patients with extrahepatic adenosquamous carcinoma to identify important factors for predicting postresection prognosis. METHODS: Thirty-six patients in Japan who underwent surgical resection for adenosquamous carcinoma of the extrahepatic biliary tract, with curative intent by the end of 2003, were studied. A retrospective review, with univariate and multivariate analyses, was performed on the clinical records of patients who underwent surgical exploration for adenosquamous carcinoma of the common bile duct. The clinical and pathologic factors that influenced patient survival were analyzed. RESULTS: The operative mortality rate in the patient cohort was 3%. The overall 1-, 3-, and 5-year survival rates were 57%, 26%, and 16%, respectively, and the median survival was 13 months. Univariate and multivariate analyses revealed that independent negative prognostic factors in resected specimens were: (1) the presence of pancreatic invasion, (2) the presence of n2 and n3 lymph node metastasis, and (3) curability C status. The presence of an abnormal arrangement of the pancreatobiliary ductal system and pathological serosal invasion of the tumor tended to be associated with poor survival. CONCLUSIONS: Curative surgical resection for adenosquamous carcinoma remains the only effective treatment, because it offers the chance of long-term survival. New adjuvant strategies are required for improvements in patient outcomes.