Clinical outcomes of endoscopic submucosal dissection for early gastric cancer in remnant stomach or gastric tube.

BACKGROUND AND STUDY AIMS: Little information exists regarding the optimal treatment of early gastric cancer (EGC) in a remnant stomach or gastric tube. The aim of this study was to assess the feasibility and clinical outcomes of endoscopic submucosal dissection (ESD) for EGC in a remnant stomach and gastric tube. PATIENTS AND METHODS: Between September 2002 and December 2009, ESD was performed in 62 lesions in 59 patients with EGC in a remnant stomach (48 lesions) or gastric tube (14 lesions). Clinicopathological data were retrieved retrospectively to assess the en bloc resection rate, complications, and outcomes. Treatment results were assessed according to the indications for endoscopic resection, and were compared with those of ESD performed in a whole stomach during the same study period. RESULTS: The en bloc resection rates for lesions within the standard and expanded indication were 100 % and 93 %, respectively. Postoperative bleeding occurred in five patients (8 %). The perforation rate was significantly higher (18 %, 11 /62) than that of ESD in a whole stomach (5 %, 69 /1479). Among the perforation cases, eight lesions involved the anastomotic site or stump line, and ulcerative changes were observed in five lesions. The 3-year overall survival rate was 85 %, with eight deaths due to other causes and no deaths from gastric cancer. CONCLUSION: A high en bloc resection rate was achieved by ESD for EGC in a remnant stomach or gastric tube; however, this procedure is still technically demanding due to the high complication rate of perforation.

Risk factors for recurrence of artificial gastric ulcers after endoscopic submucosal dissection.

It has been reported previously that artificial gastric ulcers caused by endoscopic submucosal dissection (ESD) would heal within 8 weeks, irrespective of their size and location. The aim of this retrospective study was to describe long-term outcomes of gastric ESD ulcers. Check-up of ulcers was performed by periodic endoscopy. The rate of ESD ulcer recurrence and clinicopathological factors that may relate to recurrence were assessed. During the median observation period of 33 months, a benign ulcer recurrence occurred in 10 lesions in 10 patients (2.1%). Univariate analysis showed that Helicobacter pylori infection and presence of pathological ulcer findings within the ESD specimen were significantly related to the risk of ESD ulcer recurrence. Although the frequency is low, there is a possibility of ESD ulcer recurrence in patients with H. pylori infection and in patients who undergo ESD for a lesion with ulceration.

Second-line chemotherapy for carboplatin/paclitaxel-refractory ovarian cancer: are multi-agent chemotherapies of little value truly?

PURPOSE: We examined whether second-line multi-agent chemotherapies are of any value for carboplatin/paclitaxel (TC)-refractory ovarian cancer. METHODS: Subjects included 60 patients with ovarian, peritoneal, or tubal carcinoma who received second-line platinum-based combination chemotherapy. Thirty-nine were treated with irinotecan/cisplatin or nedaplatin and 21 with docetaxel/cisplatin shortly after TC failure. Patients were divided between those who were refractory to initial platinum-based chemotherapy (n = 29, Group A) and those who were platinum-sensitive (n = 31, Group B). Efficacy and safety of the combination chemotherapies were compared between the two groups. RESULTS: Response to the combination chemotherapy was 10.3% in Group A and 41.9% in Group B. Median time to disease progression was 4.02 months and 7.21 months, respectively (p = 0.006), and median survival time was 7.89 months and 9.23 months, respectively (p = 0.003). There was no difference in response between the two regimens. Grade 3-4 hematologic toxicities were more frequent with the docetaxel regimen. CONCLUSION: The choice between agents for second-line chemotherapy for TC-refractory ovarian cancer should be based on whether the cancer was previously platinum-sensitive. With a history of such response, multi-agent chemotherapies are worth considering after TC failure. With no previous response, the expected efficacy of second-line multi-agent chemotherapy is low, suggesting the use of monochemotherapy.

The treatment of uterine leiomyosarcoma: clinical outcomes of 18 cases and the effectiveness of chemotherapy.

PURPOSE: To investigate clinical outcomes with respect to the effectiveness of chemotherapy in the treatment of uterine leiomyosarcoma. METHODS: Study subjects were 18 patients with uterine leiomyosarcoma treated surgically at our hospital between February 1986 and December 2007. A chemotherapy regimen that combined ifosfamide, epirubicine, and cisplatin (IEP) was used as the main first-line chemotherapy. RESULTS: FIGO disease stages were as follows: Stage I (n = 11), Stage II (n = 1), Stage III (n = 3), Stage IV (n = 3). Five-year overall survival of patients with Stage I-III disease was 65.3% (95% CI: 46.1-92.4%). None of patients with Stage IV disease survived for more than two years. Of seven patients who suffered advanced or recurrent disease, six received IEP; the response rate was 50%, one complete response and two partial responses. CONCLUSIONS: The combination of surgery and chemotherapy seems to be an acceptable treatment for uterine leiomyosarcoma. IEP may be an active regimen for this aggressive disease.

Clinical features of 215 stage I ovarian tumors in Japanese women.

PURPOSE: Differences of the clinical features of Stage I borderline ovarian tumors and Stage I ovarian cancer need to be clarified. METHODS: We retrospectively investigated 215 patients with Stage I ovarian tumors (67 with borderline tumors and 148 with ovarian cancer) treated between 1988 and 2001. RESULTS: Only one patient with a borderline tumor developed recurrence, while recurrence was found in 20 patients with Stage I ovarian cancer. There was a significant difference in the recurrence rate between patients with Stage Ia or Ib ovarian cancer and those with Stage Ic cancer (p = 0.007). Clear cell adenocarcinoma showed a higher recurrence rate. Among our patients with recurrence, only five in whom the recurrent tumor could be surgically resected are currently alive and disease-free. CONCLUSIONS: This study confirmed the low aggressiveness of Stage I borderline ovarian tumors and high aggressiveness of Stage Ic ovarian cancer or clear cell adenocarcinoma. In patients with recurrence, surgical resection may improve survival.

[Exposure for harvesting gastroepiploic artery graft].

We present out technique for harvesting the gastroepiploic artery (GEA). We use a Universal Stabilizer Arm and an assistant attachment to push the liver against the diaphragm, giving en enough working space to harvest the graft. Between January and December 2007, 99 isolated coronary artery bypass grafting (CABG)s were performed, and in 36 (36.4%) patients the GEA was harvested using this technique. The mean operation time was 251.1 +/- 40.5 minutes and the mean number of distal anastomosis was 3.6 +/- 0.8. The early patency rate of the GEA graft was 95%. Combined use of a Universal Stabilizer Arm and an assistant attachment provide good exposure for harvesting the GEA.

Adjuvant hysterectomy for treatment of residual disease in patients with cervical cancer treated with radiation therapy.

The objective of this retrospective study was to determine the efficacy of adjuvant hysterectomy for treatment of residual disease in cervical carcinoma treated with radiation therapy. Between 1971 and 1996, 1590 patients with carcinoma of the uterine cervix (stages I-IIIb) were treated with radiation therapy. Three months after completion of radiation therapy, the status of local control was investigated, and total abdominal hysterectomy was performed in cases in which central residual disease existed in the cervix. Of the 1590 patients, residual disease was identified in 162 patients. Among these patients, 35 showed an absence of distant metastasis or lateral parametrial invasion and underwent hysterectomy. The overall 5- and 10-year survival rates for these patients were 68.6 and 65.7%, respectively. There was no significant difference in survival between patients with squamous cell carcinoma and those with non-squamous cell carcinoma or between patients with stage I/II carcinoma and those with stage III carcinoma. With respect to treatment-related morbidity, five (14.3%) patients suffered grade III or IV complications after hysterectomy. Adjuvant hysterectomy is an effective addition to radiation therapy in the treatment of cervical cancer, even in patients with stage III disease and in those with non-squamous cell carcinoma.

Routine coagulation of visible vessels may prevent delayed bleeding after endoscopic submucosal dissection--an analysis of risk factors.

BACKGROUND AND STUDY AIM: Endoscopic submucosal dissection (ESD) has been reported to be associated with a higher complication rate than standard endoscopic mucosal resection. We aimed to clarify the risk factors for delayed bleeding after ESD for early gastric cancer (EGC). METHODS: 1083 EGCs in 968 consecutive patients undergoing ESD during a 4-year period were reviewed. Post-ESD coagulation (PEC) preventive therapy of visible vessels in the resection area, using a coagulation forceps, was introduced and mostly performed during the later 2 years. Various factors related to patients, tumors, and treatment including PEC were investigated using univariate and multivariate analysis with regard to delayed post-ESD bleeding, evidenced by hematemesis or melena, that required endoscopic treatment. RESULTS: Delayed bleeding occurred after ESD of 63 lesions (5.8 % of all lesions and 6.5 % of patients), controlled in all cases by endoscopic hemostasis; blood transfusion was required in only one case. Tumor location in the upper third of the stomach and PEC were independent factors indicating a lower rate of delayed bleeding according to both univariate and multivariate analysis. CONCLUSIONS: This retrospective study suggested that preventive coagulation of visible vessels in the resection area after ESD may lead to a lower bleeding rate.

Successful super-small-for-size graft liver transplantation by decompression of portal hypertension via splenectomy and construction of a mesocaval shunt: a case report.

We performed a successful super-small-for-size graft liver transplantation by decompressing portal hypertension via splenectomy and a mesocaval shunt. A 46-year-old woman with Child-Pugh class C liver cirrhosis associated with Wilson's disease underwent a living donor liver transplantation (LDLT). The donor had an anomalous portal vein, hepatic vein, and bile duct, so we had to use the right lateral segment for the graft. Preoperative computed tomographic (CT) volumetry showed the volume of this area to be 433 mL; graft-to-recipient weight ratio (GRWR) was 0.72; and graft-to-standard liver volume (GV/SLV) was 39.0%. However, the real volume of the resected right lateral segment was 281 g; GRWR was 0.47; and GV/SLV was 25.3%--a super-small-for-size graft. After implantation, congestion of the small graft was severe due to excessive portal hypertension. Therefore, we tried decompressing the portal vein. First, we performed splenectomy which reduced the portal pressure which remained excessive. Second, a mesocaval shunt was constructed decreasing the portal pressure from 38 to 30 cm H2O. Additionally, we initiated continuous portal injection of prostaglandin E1. The postoperative course was not smooth, but the general status slowly recovered. Over 25 cm H2O of portal hypertension was observed until postoperative day 21 when it improved. At last, the recipient was discharged on postoperative day 156. Accurate preoperative CT volumetry is important to obtain sufficient graft volume. Our case may be one of the smallest-for-size grafts that was successfully transplanted. Management of excessive portal hypertension is important for LDLT, especially using a small-for-size graft. Splenectomy and construction of a mesocaval shunt may be useful strategies to decompress the portal vein.

Spatial measurement in rotating magnetic field plasma acceleration method by using two-dimensional scanning instrument and thrust stand.

A two-dimensional scanning probe instrument has been developed to survey spatial plasma characteristics in our electrodeless plasma acceleration schemes. In particular, diagnostics of plasma parameters, e.g., plasma density, temperature, velocity, and excited magnetic field, are essential for elucidating physical phenomena since we have been concentrating on next generation plasma propulsion methods, e.g., Rotating Magnetic Field plasma acceleration method, by characterizing the plasma performance. Moreover, in order to estimate the thrust performance in our experimental scheme, we have also mounted a thrust stand, which has a target type, on this movable instrument, and scanned the axial profile of the thrust performance in the presence of the external magnetic field generated by using permanent magnets, so as to investigate the plasma captured in a stand area, considering the divergent field lines in the downstream region of a generation antenna. In this paper, we will introduce the novel measurement instrument and describe how to measure these parameters.

Persistent Primary Cytomegalovirus Infection After Deceased Donor Kidney Transplant: Ganciclovir Susceptibility of Human Cytomegalovirus With UL97 D605E Mutation: A Case Report.

BACKGROUND: Cytomegalovirus (CMV) could cause rejection in immunocompromised patients during early post-renal transplant stage. The American Transplant Society guidelines recommend prophylactic therapy with ganciclovir (GCV) for 3 to 6 months to prevent CMV infections in adult renal transplant patients. However, there is no recommended CMV treatment regimen for pediatric patients. MAIN FINDINGS: We performed deceased donor kidney transplant from an anti-CMV antibody-positive donor to an anti-CMV antibody-negative 15-year-old female recipient with end-stage renal disease caused by bilateral renal hypoplasia. One month after transplant, increase in positive cells in the CMV antigenemia assay indicated a primary CMV infection in the patient, who immediately received GCV. She was switched to foscarnet after 4 months of anti-CMV therapy because of clinical GCV resistance. CMV was isolated from the peripheral blood mononuclear cells but neutralizing antibody was not detected. Isolated CMV was susceptible to GCV and foscarnet, although it carried the UL97 D605E mutation, assumed to be associated with GCV resistance. CONCLUSIONS: The primary CMV infection presented a phenotypic clinical drug resistance, but all recovered CMV isolates were drug-susceptible even if isolated after prolonged anti-CMV therapy, indicating that immune status was more important for recovery from primary CMV infection than anti-CMV therapy.

Long-term Follow-up of Laparoscope-Assisted Living Donor Hepatectomy.

BACKGROUND: We have introduced and performed laparoscope-assisted surgery in living donor hepatectomy. The objective of this study was to investigate the long-term results of laparoscope-assisted living donor hepatectomy. METHODS: From 2006 to 2016, laparoscope-assisted living donor hepatectomy was performed in 11 patients (laparoscopic group), and conventional open living donor hepatectomy was performed in 40 patients (conventional group). Intraoperative and postoperative complications were evaluated according to the Clavien-Dindo classification and analyzed in the laparoscopic group for comparison with the conventional group. RESULTS: The median postoperative follow-up period was 88 months (range, 58-120 months) in the laparoscopic group. One donor in the conventional group died from a motor vehicle crash 16 months after surgery. All others were alive and returned to their preoperative activity level. Regarding intraoperative and early (≤90 days after surgery) postoperative complications, 1 patient (1/11, 9%) showed biliary fistula (Grade IIIa) in the laparoscopic group. In the conventional group, 6 patients (6/40, 15%) showed surgical complications of Grade I in 2 patients and Grade II in 4 patients. Regarding late (>90 days after surgery) postoperative complications, biliary stricture was observed in 1 patient of the laparoscopic group; this patient developed hepatolithiasis 6 years after surgery, and endoscopic lithotomy and extracorporeal shockwave lithotripsy were performed, resulting in successful treatment. Late complications were not observed in the conventional group. CONCLUSION: One donor in the laparoscopic group showed Grade IIIa late complications. The introduction of laparoscopic surgery to living donor hepatectomy should be performed carefully.

Prognostic heterogeneity of the seventh edition of UICC Stage III gallbladder carcinoma: Which patients benefit from surgical resection?

BACKGROUND: This study sought to evaluate the prognostic heterogeneity of Stage III (Union for International Cancer Control, seventh edition) gallbladder carcinoma. METHODS: Of 175 patients enrolled with gallbladder carcinoma who underwent radical resection, 22 were classified with Stage IIIA disease (T3N0M0) and 46 with Stage IIIB disease (T2N1M0 [n = 23] and T3N1M0 [n = 23]). The median number of retrieved lymph nodes per patient was 18. RESULTS: This staging system failed to stratify outcomes between Stages IIIA and IIIB; survival after resection was better for patients with Stage IIIB disease than for patients with Stage IIIA disease, with 5-year survival of 54.9% and 41.0%, respectively (p = 0.366). Multivariate analysis for patients with Stage III disease revealed independently better survival for patients with T2N1M0 than for patients with T3N0M0 (p = 0.016) or T3N1M0 (p = 0.001), with 5-year survival of 77.0%, 41.0%, and 31.0%, respectively. When N1 status was subdivided according to the number of positive nodes, 5-year survival in patients with T2M0 with 1-2 positive nodes, T2M0 with ≥3 positive nodes, T3M0 with 1-2 positive nodes, and T3M0 with ≥3 positive nodes was 83.3%, 50.0%, 45.8%, and 0%, respectively (p < 0.001). CONCLUSIONS: The prognosis of T2N1M0 disease was better than that of T3N0/1M0 disease, suggesting that not all node-positive patients will have uniformly poor outcomes after resection of gallbladder carcinoma. T2M0 with 1-2 positive nodes leads to a favorable outcome after resection, whereas T3M0 with ≥3 positive nodes indicates a dismal prognosis.

Murine strain differences in ovotoxicity following intraovarian injection with benzo(a)pyrene, (+)-(7R,8S)-oxide, (-)-(7R,8R)-dihydrodiol, or (+)-(7R,8S)-diol-(9S,10R)-epoxide-2.

Murine ovarian tumors produced by polycyclic aromatic hydrocarbons like benzo(a)pyrene (BP) require small oocyte destruction. Small oocyte destruction was evaluated in C57BL/6N (B6), DBA/2N (D2), and C57BL/6J X DBA/ 2JF1 (B6D2F1) mice following intraovarian injection with BP, (+)-( 7R ,8S)-oxide, (-)-( 7R , 8R )-dihydrodiol [(-)-DHD], or (+)-( 7R ,8S)-diol-(9S, 10R )-epoxide-2 [(+)- DE2 ] at doses ranging from 0.01 to 30 micrograms/ovary. BP, (-)-DHD, and (+)- DE2 produced small oocyte destruction in a dose-dependent fashion. The (+)-( 7R ,8S)-oxide did not destroy small oocytes at the highest dose tested (10 micrograms/ovary). The rank orders of the calculated doses which resulted in the destruction of 50% of the small oocytes (ED50S) for small oocyte destruction were BP approximately equal to (-)-DHD greater than (+)- DE2 in all three groups of mice. However, the ED50S for BP and (-)-DHD differed considerably among B6, D2, B6D2F1 mice; ED50S were smallest in B6 mice and largest in D2 mice. The ED50S for oocyte destruction in B6D2F1 mice were intermediate or similar to ED50S for B6 mice, depending on the method used for calculation. In spite of large strain differences in ED50S for BP and (-)-DHD, the ED50S for (+)- DE2 were similar in B6, D2, and B6D2F1 mice. The similar ED50 for (+)- DE2 suggests that it is an ultimate ovotoxin and ovarian carcinogen and that the target molecule(s) and mechanism(s) of detoxification are similar in B6, D2, and B6D2F1 mice.

Wireless Multichannel Neural Recording With a 128-Mbps UWB Transmitter for an Implantable Brain-Machine Interfaces.

Simultaneous recordings of neural activity at large scale, in the long term and under bio-safety conditions, can provide essential data. These data can be used to advance the technology for brain-machine interfaces in clinical applications, and to understand brain function. For this purpose, we present a new multichannel neural recording system that can record up to 4096-channel (ch) electrocorticogram data by multiple connections of customized application-specific integrated circuits (ASICs). The ASIC includes 64-ch low-noise amplifiers, analog time-division multiplexers, and 12-bit successive approximation register ADCs. Recorded data sampled at a rate of 1 kS/s are multiplexed with time division via an integrated multiplex board, and in total 51.2 Mbps of raw data for 4096 ch are generated. This system has an ultra-wideband (UWB) wireless unit for transmitting the recorded neural signals. The ASICs, multiplex boards, and UWB transmitter unit are designed with the aim of implanting them. From preliminary experiments with a human body-equivalent liquid phantom, we confirmed 4096-ch UWB wireless data transmission at 128 Mbps for distances below 20 mm .

Successful Endoscopic Management of Acute Necrotic Pancreatitis and Walled Off Necrosis After Auxiliary Partial Orthotopic Living-Donor Liver Transplantation: A Case Report.

Endoscopic management of acute necrotic pancreatitis and walled off necrosis is less invasive than surgical treatment and has become the 1st choice for treating pancreatic necrosis and abscess. We treated a case of acute necrotic pancreatitis and walled off necrosis after auxiliary partial orthotopic living-donor liver transplantation (APOLT). A 24-year-old woman was admitted to our university hospital for removal of the internal biliary stent, which had already been placed endoscopically for the treatment of biliary stricture after APOLT. She had been treated for acute liver failure by APOLT 10 years before. After we removed the internal stent with the use of an endoscopic retrograde approach, she presented with severe abdominal pain and a high fever. Her diagnosis was severe acute pancreatitis after endoscopic retrograde cholangiography (ERC). Her symptoms worsened, and she had multiple organ failure. She was transferred to the intensive care unit (ICU). Immunosuppression was discontinued because infection treatment was necessary and the native liver had already recovered sufficiently. After she had been treated for 19 days in the ICU, she recovered from her multiple organ failure. However, abdominal computerized tomography demonstrated the formation of pancreatic walled off necrosis and an abscess on the 20th day after ERC. We performed endoscopic ultrasonography-guided abscess drainage and repeated endoscopic necrosectomy. The walled off necrosis diminished gradually in size, and the symptoms disappeared. The patient was discharged on the 87th day after ERC. This is the 1st report of a case of acute necrotic pancreatitis and walled off necrosis that was successfully treated by endoscopic management after APOLT.

Successful Re-resection for Locally Recurrent Retroperitoneal Liposarcoma at Four Years After Ex Vivo Tumor Resection and Autotransplantation of the Liver: A Case Report.

Surgical resection should be considered for isolated locally recurrent retroperitoneal liposarcomas. We experienced a case of successful re-resection for locally recurrent retroperitoneal liposarcomas 4 years after ex vivo tumor resection and autotransplantation of the liver. A 75-year-old man was admitted to our hospital. His diagnosis was local recurrence of liposarcomas. He had previously undergone ex vivo tumor resection and autologous orthotopic liver transplantation for a retroperitoneal tumor 4 years earlier. The resected tumor size was 23.5 × 15.5 × 12.5 cm. The tumor was revealed by means of histopathologic study to be a myxoid liposarcoma. Follow-up computerized tomography showed 2 recurrent tumors in the retropancreatic and para-aortic lesions. Although adhesion was severe within the operative field, we successfully performed complete en bloc re-resection of each recurrent tumor. The operative time was 250 minutes, and blood loss was 300 mL. The resected tumor sizes were 3.9 × 3.2 × 1.5 cm and 4.5 × 3.3 × 3.0 cm. The tumors were revealed by means of histopathologic study to be dedifferentiated liposarcomas. Postoperative complications included intestinal obstruction and colocutaneous fistula formation, both of which were treated surgically. The patient was discharged in an ambulatory state at 80 days after re-resection of the recurrent tumors. At the time of writing, he was alive with no evidence of recurrence, 14 months after re-resection and 62 months after primary ex vivo tumor resection. This is the first case of successful surgical re-resection for locally recurrent liposarcoma after ex vivo tumor resection and autotransplantation of the liver.

Six-Year Graft Survival After Partial Pancreas Heterotopic Auto-Transplantation: A Case Report.

BACKGROUND: Long-term graft survival of partial pancreas auto-transplantation after total pancreatectomy has not been clarified. The clinical implications of repeat completion pancreatectomy for locally recurrent pancreatic carcinoma in the remnant pancreas after initial pancreatectomy also have not been clarified. METHODS: We have previously reported a 61-year-old woman presenting with re-sectable carcinoma of the remnant pancreas at 3 years after undergoing a pylorus-preserving pancreaticoduodenectomy for invasive ductal carcinoma of the pancreas head. We also performed distal pancreas auto-transplantation with the use of a part of the resected pancreas to preserve endocrine function. RESULTS: The patient was discharged at 20 days after surgery without any complications. She had been followed regularly in our outpatient clinic. She had been treated with S-1 as adjuvant chemotherapy; 72 months after the completion total pancreatectomy with distal partial pancreas auto-transplantation, the patient was alive without any evidence of the pancreatic carcinoma recurrence. The pancreas graft was still functioning with a blood glucose level of 112 mg/dL, HbA1C of 6.7%, and serum C-peptide of 1.2 ng/mL; and urinary C-peptide was 11.6 µg/d. CONCLUSIONS: Our patient demonstrated that repeated pancreatectomies can provide a chance for survival after a locally recurrent pancreatic carcinoma if the disease is limited to the remnant pancreas. An additional partial pancreas auto-transplantation was successfully performed to preserve endocrine function. However, the indications for pancreas auto-transplantation should be decided carefully in the context of pancreatic carcinoma recurrence.