Culture-based bacterial evaluation of the appendix lumen and antibiotic susceptibility of acute appendicitis in Japan: A single-center retrospective analysis.

The question of whether to perform an appendectomy or conservative treatment for acute appendicitis can differ depending on the facility or surgeon, but antibiotic treatment is administered regardless of whether an appendectomy or conservative treatment is selected. We investigated the contemporary bacteriology for acute appendicitis and evaluated the antibiotic sensitivity of the bacteria that are currently associated with appendicitis. We retrospectively analyzed the bacterial culture results and antibiotic susceptibility of 141 patients who underwent appendicitis surgery, including the identification and antimicrobial susceptibility of the cultured bacteria within the excised appendices. Bacterial cultures were positive in 131 cases (92.9%). The most commonly isolated bacteria were Escherichia coli (90 isolates, 66.7%), followed by Enterococcus species (n = 19, 14.5%), Pseudomonas aeruginosa (n = 18, 13.7%), Streptococcus species (n = 15, 11.5%), and Klebsiella species (n = 8, 6.1%). Eight strains (8.8%) of E coli were extended-spectrum ß-lactamase producers, and ten strains (11.1%) were fluoroquinolone-resistant. Tazobactam/piperacillin and meropenem inhibited the growth of 100% of the major identified bacteria. The patients with appendicoliths had a significantly higher bacterial culture rate. Enterococcus species were frequently isolated from the patients with complicated appendicitis. For the antibiotic treatment of appendicitis, it is essential to understand the patient's microbiological profile and antibiotic susceptibilities. Research from Asian countries such as Japan can enhance our knowledge of regional antibiotic resistance patterns and inform effective treatment strategies.

Three Curative Pancreatectomies for the Metachronous Appearance of Pancreatic Invasive Ductal Adenocarcinoma.

We report a rare case of a patient who underwent 3 successful curative operations for the metachronous appearance of pancreatic cancer. In July 2007, a 54-year-old woman underwent pylorus-preserving pancreaticoduodenectomy. In March 2010, a tumor measuring 9 mm in diameter was detected in the tail of the pancreas on computed tomography (CT) and magnetic resonance imaging. The pancreas tail was subsequently resected while preserving the pancreatic body. In February 2011, CT revealed a cystic tumor measuring 2.5 cm in diameter in the remnant pancreatic body without any metastasis; therefore, total resection of the residual pancreas was performed in April 2011. The first resected tumor was histopathologically diagnosed as undifferentiated adenocarcinoma with osteoclast-like giant cells. Additionally, the third resected tumor had similar undifferentiated components. Contrarily, the second resected tumor was diagnosed as a well-differentiated tubular adenocarcinoma. We consider that the tumor from the third operation was an intra-pancreatic metastasis of the primary cancer and that the tumor from the second operation was the second primary cancer. The patient responded well with good control of surgical diabetes for 92 months since the last pancreatectomy. This case suggested that aggressive repeated resection for recurrent pancreatic invasive ductal adenocarcinoma is beneficial in limited cases.

Pylorus-preserving pancreatoduodenectomy for pancreatic head cancer after surgery for esophageal cancer with gastric tube reconstruction in a long-term survivor: A case report.

INTRODUCTION: To maintain the blood circulation of the gastric tube in pylorus-preserving pancreatoduodenectomy (PPPD) for periampullary cancer after esophagectomy for esophageal cancer, it is necessary to preserve the gastroduodenal artery and its branch, the right gastroepiploic artery, which are usually resected for more convenient, complete, and effective lymph node dissection. Here we report the case of a patient with a postoperative survival period of more than 5 years. PRESENTATION OF CASE: A 79-year-old man, who underwent subtotal esophagectomy and gastric tube reconstruction 11 years ago, was diagnosed with pancreatic head cancer during routine examination 5 years after the esophageal surgery. After placement of a coronary artery stent for an arterial branch stenosis incidentally found during preoperative screening electrocardiogram, he underwent pancreatic surgery. As the tumor did not extend to the anterior surface of the pancreas and as there were no swollen lymph nodes in the area, the gastroduodenal artery, the gastroepiploic artery and vein could be preserved. Elective PPPD was conducted without incident, and good preoperative gastric tube circulation was maintained postoperatively. Reconstruction was performed according to the modified Child procedure with duct-to-mucosa stentless pancreaticojejunostomy. The postoperative course was uneventful and though it took the patient a long time to overcome the physical decline, he remains alive with no recurrent disease over 5 years post-operation. CONCLUSION: Although PPPD may be performed after esophagectomy with gastric tube reconstruction, it is still unclear how the risk of recurrence is affected. Therefore, the indications of this procedure should always be carefully considered.

Efficacy of Self-Expandable Metallic Stent Inserted for Refractory Hemorrhage of Duodenal Cancer.

Because of advances in the technology of gastrointestinal endoscopy and improvements in the quality of stents, it has become routine to place a stent as palliative therapy for malignant gastrointestinal obstruction. On the other hand, stent placement for malignant gastrointestinal hemorrhage has scarcely been reported, although it may be performed for hemorrhage of the esophageal varicose vein. We recently experienced a patient with refractory hemorrhage from an unresectable duodenal cancer who underwent placement of a self-expandable metallic stent (SEMS) and thereafter had no recurrence of the hemorrhage. A 46-year-old man underwent laparotomy to radically resect a cancer in the third portion of the duodenum, which invaded widely to the superior mesenteric vein and its branches and was considered unresectable. After stomach-partitioning gastrojejunostomy was performed, chemotherapy was initiated according to the regimen of chemotherapy of far advanced gastric cancer. One year and 4 months after induction of chemotherapy, gastrointestinal hemorrhage occurred. Upper gastrointestinal endoscopy revealed the hemorrhage oozing from the duodenal cancer, and endoscopic hemostasis, such as injection of hypertonic saline epinephrine and argon plasma coagulation, was unsuccessful. Twenty days after emergence of the hemorrhage, an endoscopic covered SEMS was placed with confirmation by fluoroscopy. Immediately after placement of the stent, the tarry stool stopped and the anemia ceased to progress. The recurrence of the hemorrhage has not been confirmed without migration of the stent. SEMS is an effective hemostatic procedure for malignant refractory hemorrhage.

An FDG-PET/CT-positive lesion mimicking local recurrence of colon cancer 5 years after radical colectomy.

BACKGROUND: Radical resection of colorectal cancer yields satisfactory results. Even if the cancer recurs, long-term survival is expected through further surgical resection of the recurrent disease. For early detection of recurrent lesions, we routinely perform periodic blood tests and imaging studies, in which 18F-fluorodeoxyglucose-glucose positron emission tomography (FDG-PET) plays an important role, for lesion differentiation. We encountered a case of a benign lesion, which had been clinically diagnosed as recurrence of resected colon cancer by FDG-PET/computed tomography (CT). CASE REPORT: A 69-year-old woman underwent radical resection of stage II sigmoid colon cancer. Five years after the operation, local recurrence was suspected on the basis of follow-up CT examination findings. Since the standardized uptake value (SUV) on FDG-PET/CT was 13.3, we diagnosed the lesion as a postoperative local recurrence and performed surgical resection of the lesion. The lesion was conclusively diagnosed as benign fatty tissue, including a fibrovascular component, by histopathological examination. CONCLUSIONS: FDG-PET is a very useful technique for differentiating benign from malignant disease. In colorectal cancer, FDG-PET not only enables the differentiation of malignancy in the primary tumor, but also the confirmation of metastasis and postoperative recurrence. However, even if the SUV is high, as in the presented case, the lesion may eventually be diagnosed as benign. Therefore, further advances in the PET technique are expected along with the development of more useful modalities.

Technical procedures causing biliary complications after hepaticojejunostomy in pancreaticoduodenectomy.

BACKGROUND: Although pancreaticoduodenectomy has been established as a standard operation for pancreatobiliary diseases, postoperative biliary complications still exist and impair patient quality of life. METHODS: We enrolled 67 patients who underwent pancreaticoduodenectomy. Patients were divided into 2 chronological groups representing different surgical procedures: group A (G-A) included patients treated between 2003 and 2006 and group B (G-B) included patients treated later. We compared surgical procedures and postoperative biliary complications between the groups. RESULTS: The number of stitches at hepaticojejunostomy was 33.2 ± 8.4 in G-A and 14.0 ± 2.3 in G-B. A biliary drainage stent was placed in 31 of 32 cases in G-A and in none of the 35 cases in G-B. For each surgical procedure, there was a significant difference between the groups. Bile leakage occurred in 9.4% of G-A patients and 2.9% of G-B patients. The serum alkaline phosphatase level was significantly higher in G-A than in G-B. Moreover, the number of patients hospitalized for cholangitis was significantly greater in G-A than in G-B. CONCLUSION: Among procedure-related factors pertaining to hepaticojejunostomy in pancreaticoduodenectomy, the number of anastomotic stitches and the placement of a biliary drainage stent were confirmed to affect the development of an anastomotic stricture.

Long-term survival after sequential chemotherapy and surgery for advanced gastric cancer.

INTRODUCTION: We experienced a case with long relapse-free survival after successful treatment of chemotherapy and surgery to advanced gastric cancer. PRESENTATION OF CASE: A 56-year-old man was examined because of rapid weight loss and was diagnosed as having far-advanced gastric cancer with portal vein tumor thrombus (PVTT) and liver, lymph node and peritoneal metastases. Immediately after beginning chemotherapy, gastric obstruction due to gastric cancer was discovered. Therefore gastrojejunostomy, a bypass operation, was performed, and this was followed by the first course chemotherapy with S-1 and cisplatin. After 4 courses of this regimen were completed, PVTT and the peritoneal metastasis could no longer be confirmed, and new lesion had not appeared; therefore, the patient underwent a radical operation with distal gastrectomy, lymph node dissection and partial hepatectomy. After the operation, he received second-line chemotherapy with S-1 and paclitaxel for 1 year. He has been in good health without any signs of recurrence for 3 years and 8 months after the radical operation. DISCUSSION AND CONCLUSION: Although complete recovery from far-advanced gastric cancer is rarely expected, this case demonstrates that long-term survival is achievable with carefully considered treatment plans.

Hepatectomy preserving drainage veins of the posterior section for liver malignancy invading the right hepatic vein: an alternative to right hepatectomy.

BACKGROUND: Although a right hepatectomy (RH) traditionally has been performed for liver tumors infiltrating the main trunk of the right hepatic vein (RHV), the presence of drainage veins of the posterior section (DVPS) beside the RHV provides a chance to preserve their draining area even if the main trunk of the RHV is removed. METHODS: Since 2005, we systematically have performed DVPS-preserving hepatectomies whenever possible. In the present study, we describe our experience treating 12 consecutive patients who underwent this procedure. RESULTS: We performed the following types of liver resections concomitant with the main trunk of the RHV without packed red cell transfusion, liver failure, or 90-day mortality: extended right anterior sectionectomy in 2 patients, extended segmentectomy 7 in 3, extended segmentectomy 8 in 2, and partial resection of segment 7 in 2 and segment 8 in 3. Postoperative morbidity was observed in 4 (33%) cases, all of which had pleural effusion requiring a tap. A free resection margin was obtained in all patients. CONCLUSIONS: This procedure could be a useful alternative to RH, providing a chance for radical liver resection with minimal parenchymal sacrifice in selected patients with DVPS.

COP35, a cholangiocarcinoma-binding oligopeptide, interacts with the clathrin heavy chain accompanied by GRP78.

Cholangiocarcinoma (CCA) is a common carcinoma of the liver, and the majority of patients with CCA have a poor prognosis due to the lack of effective nonsurgical therapies in addition to its rapid progression and inoperability at the time of diagnosis. The development of novel nonsurgical therapeutics that efficiently target CCA could significantly improve the prognosis for patients presenting with CCA. Here, we describe the iterative production and characterization of a novel peptide, designated COP35 (CCA-binding oligopeptide 35), which binds selectively to human CCA, identified by bacteriophage biopanning using the intrahepatic CCA cell line RBE and the normal cholangiocyte cell line MMNK-1. COP35 was found to augment the growth inhibitory effects of 5-fluorouracil (5-FU) against RBE cells. Utilizing pull-down assay and liquid chromatography, we identify the clathrin heavy chain accompanied by GRP78/BiP as a COP35-binding partner. In summary, we identify COP35 as a possible candidate for peptide-targeted therapies for CCA.

Identification of oligopeptide binding to colon cancer cells separated from patients using laser capture microdissection.

The development of intravascular conjugates that efficiently deliver genes or drugs to tumors is limited by the lack of efficacious targeting ligands. Small targeting peptides, such as those iterated by phage display technology, offer enormous potential for these applications. The majority of reports published to date have focused on the identification of peptides isolated for their ability to bind to human cancer cell lines in vitro, and have failed to account for the loss of polarization and de-differentiation of such cells from their in vivo state. Here, we report a novel approach for the identification of peptides capable of binding specifically to cancer cells derived from clinically resected human colon cancer. In this strategy, laser capture microdissection (LCM) is performed on a surgically resected colon cancer specimen to separate only cancer cells from the specimen. Subsequently, biopanning was performed on the LCM-selected colon cancer cells to identify peptide sequences that bound specifically to them. A peptide containing the SPT motif was selected as the most promising consensus sequence binding specifically to the LCM-selected colon cancer cells. Phage clones displaying the SPT motif demonstrated 9-fold higher binding to colon cancer cells derived from a patient than insertless phage (p < 0.05), while, recovery of the SPT phage from the colon cancer cell lines DLD-1 and HCT-15 was 7-fold higher than that of the control insertless phage (p < 0.05). The binding of SPT phage to colon cancer cells from the patient was confirmed by immunofluorescence. Additionally, a synthesized SPT-containing peptide (SPTKSNS) showed binding activity in the absence of mitogenic effects on colon cancer cells in vitro. In summary, we have introduced LCM into a biopanning procedure and identified a small peptide that binds preferentially to colon cancer cells derived from a clinically resected sample. This procedure could be applicable for the design of customized cancer cell targeting methodologies using clinical biopsy samples from human subjects.