Clinicopathological features of hepatoid adenocarcinoma of the stomach: A multicenter retrospective study.

BACKGROUND: Hepatoid adenocarcinoma of the stomach (HAS) is a rare and aggressive subtype of gastric cancer (GC), accounting for less than 1% of all cases. It is characterized by frequent liver metastasis recurrence and a poorer prognosis than conventional GC. However, established treatment guidelines for HAS are currently not available.In this report, we present the results of a clinicopathological study of 19 patients diagnosed with HAS, including seven patients with liver metastasis, conducted by the Hiroshima Surgical Study Group of Clinical Oncology (HiSCO) between 2016 and 2018. AIMS: The aim of the study was to retrospectively observe the outcomes of HAS with gastrectomy and hepatectomy for liver metastasis and determine relevant prognostic factor. We also examined the criteria and outcomes of hepatectomy for liver metastasis and aimed to suggest the optimal treatment for HAS, including chemotherapy. METHODS AND RESULTS: A total of 2147 patients underwent gastrectomy for GC at HiSCO-affiliated institutions during the study period; 19 patients, all male with a mean age of 70.9 years, were diagnosed with HAS by hematoxylin-eosin and immunohistochemical staining. Patients underwent gastrectomy at varying pathological stages: six at Stage I, three at Stage II, seven at Stage III, and three at Stage IV. Ten patients received postoperative chemotherapy and the 5-year survival rate was 67.7% after gastrectomy. Among the seven patients with pre or postoperative liver metastasis, five patients underwent hepatectomy. Although one patient had recurrence, the 3-year survival rate was 100% after hepatectomy. CONCLUSION: Contrary to previous reports suggesting a 3-year survival rate of approximmately 30% for HAS, our findings indicate that the prognosis for HAS may not be as poor as reported previously. This study contributes valuable insights into the management and potential treatment strategies for HAS.

Intraoesophageal pressure in patients receiving proximal gastrectomy with hinged double flap method for gastric cancer: a retrospective cohort study.

Background: Objective functional assessment of esophagogastric anastomosis in patients who underwent proximal gastrectomy with the hinged double flap method for gastric cancer has not been well investigated. This study aimed to perform a functional analysis of reconstruction using high-resolution impedance manometry (HRIM). Materials and methods: The authors enroled 25 patients who underwent proximal gastrectomy for gastric cancer between May 2015 and April 2020 and subsequently underwent HRIM postoperatively. Eligible questionnaires [Postgastrectomy Syndrome Assessment Scale-37 (PGSAS-37)] were retrieved from 16 patients. The association between HRIM data and PGSAS-37 was analyzed. Results: The amplitudes of distal oesophageal peristaltic waves, contractile front velocity, and distal latency assessed by HRIM were almost normal after surgery. Most patient's lower oesophageal sphincter (LES) resting pressure created by the hinged double flap was within normal limits. Conversely, LES residual pressure values during swallowing-induced relaxation were abnormally high in most patients, and the lower the values, the more severe the reflux and diarrhoea symptoms (P=0.038, P=0.041, respectively). In addition, even when the integrated relaxation pressure (IRP) was normal, lower values corresponded to more severe reflux symptoms (P=0.020). The required LES pressure may be higher after proximal gastrectomy because of the relatively higher intragastric pressure due to the reduced volume of the remnant stomach. This also suggests that swallowing-induced relaxation of the LES was considered a trigger for oesophageal reflux in post-proximal gastrectomy patients. Conclusion: LES residual pressure and IRP values in HRIM correlated with reflux symptoms in patients after proximal gastrectomy.

Preoperative High C-Reactive Protein to Albumin Ratio Predicts Short- and Long-Term Postoperative Outcomes in Elderly Gastric Cancer Patients.

Individualized preoperative assessment of the general condition of elderly patients with gastric cancer is necessary for appropriate surgical treatment planning. This study investigated the efficacy of preoperative markers that could be easily calculated from preoperative peripheral blood to predict the short- and long-term postoperative outcomes of gastrectomy. In total, 571 patients who underwent R0 surgical resection for gastric cancer were enrolled. In the elderly patient group (≥65 years old), univariate analyses revealed that the incidence of postoperative complications was associated with poor performance status (p = 0.012), more comorbidities (p = 0.020), high C-reactive protein to albumin ratio (CAR, p = 0.003), total gastrectomy (p = 0.003), open approach (p = 0.034), blood transfusion (p = 0.002), and advanced cancer (p = 0.003). Multivariate analysis showed that a high CAR was associated with a high incidence of postoperative complications (p = 0.046). High CAR was also associated with poor OS (p = 0.015) and RFS (p = 0.035). However, these trends were not observed among younger patients (<65 years old). Preoperative CAR may play a significant role in predicting short- and long-term surgical outcomes, particularly in elderly patients with gastric cancer.

Establishment of a novel overlay culture method that enables immune response assessment using gastric cancer organoids.

Organoid technology, a novel 3D cell culture system, can reproduce a patient's cancer and may be a novel immunotherapy experimental model. However, currently no gastric cancer organoid (GCO) models in which the organoid and immune cells are in free contact and sufficiently react with each other exist. In this study, we aimed to create a coculture model in which immune cells can move freely and stay in contact with GCOs. We coated the bottom surface of the plate with Matrigel and adhered stem cells to the Matrigel surface, instead of completely embedding them in Matrigel to culture organoids. This method allowed GCOs to grow on the Matrigel surface while maintaining a three-dimensional structure and reproducing the characteristics of the patient's cancer. We cocultured GCOs and immune cells. Using this model, immune cells could freely move and were in sufficient contact with the cultured GCOs. Our model allowed real-time observation of the immune response and tumor destruction with time. In addition, the GCO killing assay was assessed with natural killer cells from the same patient. This organoid culture model enabled repeated evaluation of the GCO killing assay with various immune cells in vitro. We established a new experimental model that allowed free movement of immune cells and sufficient contact with GCOs. Using this model, it may be possible to predict the effects of immune checkpoint inhibitors in vitro (using GCOs) before administering them to patients.

The involvement of circulating CD69+ CD56bright natural killer cells in weight loss before bariatric surgery: A retrospective cohort study.

As the impact of the immune system on weight loss prior to bariatric surgery has never been proven, we elucidated the clinical utility of the immune system as an indicator of preoperative weight loss before bariatric surgery. We examined the relationships between preoperative weight loss and biochemical and clinical data at the initial visit in 34 obese patients. Patients were divided according to preoperative weight loss, and peripheral blood mononuclear cells were compared using flowcytometry. The Δpreoperative excess weight loss [Δpre-EWL: pre-EWL (%)/period of preoperative weight loss (days)] showed negative correlations with total and subcutaneous fat area (P = .02, r = -0.41, P = .02, r = -0.42 respectively). The Δpre-EWL and Δpreoperative total weight loss (Δpre-TWL) were negatively correlated with white blood cell count, lymphocyte count, and C-reactive protein (CRP) levels at the initial visit (Δpre-EWL; P = .02, r = -0.37, P = .01, r = -0.41, P = .008, r = -0.45, Δpre-TWL; P = .01, r = -0.40, P = .01, r = -0.42, P = .01, r = -0.42, respectively). Multivariate regression modeling showed that both Δpre-EWL and Δpre-TWL were significantly associated with lymphocyte count (Δpre-EWL; P = .01, Δpre-TWL; P = .01). A comparison between the high (Δ pre-EWL > 0.098) and low weight loss group (Δ pre-EWL < 0.098) demonstrated a significant difference in the expression of the activation marker CD69 on CD56bright Natural killer (NK) cells (P = .01), whereas there was no difference in the frequency of T cells, Natural killer T cells, or NK cells. Additionally, high CRP levels were associated with CD69 expression in CD56bright NK cells (P = .01, R = 0.57). Peripheral lymphocytes, especially CD69-positive CD56bright NK cells, are involved in preoperative weight loss after bariatric surgery, and systemic inflammation may inhibit weight loss before surgery.

Successful management of multiple liver metastasis from gastric cancer with second conversion surgery: A case report.

INTRODUCTION: Most conversion surgeries for patients with stageIV gastric cancer are performed on patients who have responded to first-line chemotherapy. Although conversion surgery after third-line chemotherapy with nivolumab has been reported, there are no cases wherein second conversion surgery was performed after third-line chemotherapy with nivolumab. PRESENTATION OF CASE: A 72-year-old man presented with gastric cancer and an enlarged regional lymph node, and early esophageal cancer was identified after endoscopic submucosal dissection. After S-1 plus oxaliplatin as first-line chemotherapy, staging laparoscopy was performed, and liver metastasis was confirmed. The patient underwent a total gastrectomy with D2 lymphadenectomy, hepatic left lateral segmentectomy, and partial hepatectomy. One year after conversion surgery, new liver metastases appeared. He received nab-paclitaxel plus ramucirumab and nivolumab as the second and third-line chemotherapy, respectively. Liver metastases were significantly reduced following these courses of chemotherapy. The patient underwent partial hepatectomy as second conversion surgery. Although nivolumab was continued after the second conversion surgery, new para-aortic lymph node metastasis and bilateral hilar lymph node metastasis appeared. However no new metastasis appeared in the liver and he survived for 60 months after first-line chemotherapy. DISCUSSION: A second conversion surgery with stageIV gastric cancer after third-line chemotherapy with nivolumab is rare. Multiple hepatectomy as conversion surgery may be an option to control liver metastases. CONCLUSION: Multiple hepatectomy as conversion surgery may be effective in controlling liver metastases. However, when to perform conversion surgery and the adequate selection of the patient are the most difficult and important.

A Retrospective Study on the Relationship Between Cognitive Function and Social Function in Patients With Schizophrenia.

Background: Social dysfunction is associated with decreased activity, employment difficulties, and poor prognosis in patients with schizophrenia. Cognitive functions, such as attention and processing speed, have been implicated in the social functions of schizophrenia patients; however, the relationship between cognitive functions and social functions remains unclear. Thus, understanding the factors that influence social functioning can aid the development of therapeutic strategies for schizophrenia. Herein, we retrospectively analyzed factors that influence social functioning in patients with schizophrenia. Methods: Patient background, intelligence quotient (IQ) scores, Japanese version of the Brief Assessment of Cognition in Schizophrenia (BACS-J) scores, the dose of antipsychotic drugs, Positive and Negative Syndrome Scale (PANSS) scores, and the factors influencing each subscale of the Japanese version of the Social Functioning Scale (SFS-J) were evaluated using univariate and multivariate analyses. The Bonferroni correction was applied to evaluate the correlation between each factor in the univariate analysis. In multivariate analysis, independent variables were selected using a stepwise method. In each model, considering the sample size, the maximum number of variables extracted using the stepwise method was set to three. We then calculated the standard partial regression coefficient (standard ß) between the SFS-J subscale scores and each factor. Results: Data from 36 patients were analyzed. The average age, illness duration, and total length of hospitalization were 57.8 years, 34.8 years, and 196.7 months, respectively. Of the seven significant correlations with the SFS-J subscale in the univariate analysis, only three were significant in the multivariate analysis model. According to the multivariable model, BACS-J verbal fluency positively correlated with SFS-J withdrawal, interpersonal communication, and employment/occupation. Moreover, BACS-J token motor and educational history were positively correlated with SFS-J recreation and SFS-J employment/occupation, respectively. PANSS scores, IQ scores, and doses of antipsychotic drugs did not show clear associations with SFS-J scores. Conclusions: In conclusion, there were significant correlations between BACS-J subscale scores for cognitive functioning and SFS-J subscale scores for social functioning in patients with schizophrenia.

Distal Gastrectomy for Symptomatic Stage IV Gastric Cancer Contributes to Prognosis with Acceptable Safety Compared to Gastrojejunostomy.

BACKGROUND: The prognostic prolongation effect of reduction surgery for asymptomatic stage IV gastric cancer (GC) is unfavorable; however, its prognostic effect for symptomatic stage IV GC remains unclear. We aimed to compare the prognosis of gastrectomy and gastrojejunostomy for symptomatic stage IV GC. METHODS: This multicenter retrospective study analyzed record-based data of patients undergoing palliative surgery for symptomatic stage IV GC in the middle or lower-third regions between January 2015 and December 2019. Patients were divided into distal gastrectomy and gastrojejunostomy groups. We compared clinicopathological features and outcomes after propensity score matching (PSM). RESULTS: Among the 126 patients studied, 46 and 80 underwent distal gastrectomy and gastrojejunostomy, respectively. There was no difference in postoperative complications between the groups. Regarding prognostic factors, surgical procedures and postoperative chemotherapy were significantly different in multivariate analysis. Each group was further subdivided into groups with and without postoperative chemotherapy. After PSM, the data of 21 well-matched patients with postoperative chemotherapy and 8 without postoperative chemotherapy were evaluated. Overall survival was significantly longer in the distal gastrectomy group (p = 0.007 [group with postoperative chemotherapy], p = 0.02 [group without postoperative chemotherapy]). CONCLUSIONS: Distal gastrectomy for symptomatic stage IV GC contributes to prognosis with acceptable safety compared to gastrojejunostomy.

Complete Response for Advanced Hepatocellular Carcinoma by Conversion Surgery Therapy Following a Good Response of Regorafenib Despite Rapid Progressive Disease with Sorafenib.

A 68-year-old man with hepatocellular carcinoma (HCC) visited his previous hospital due to abdominal pain and was diagnosed with ruptured HCC. Before visiting our hospital, he underwent HCC treatment at his previous hospital, but his tumors did not improve. Although he started treatment with sorafenib, the tumors rapidly grew. Subsequently, regorafenib was given, and the tumors shrank. After 22 months being treated with regorafenib, HCC reoccurred, with a new lung metastasis and a contrast-enhanced nodule on the peritoneal dissemination appearing. He underwent conversion surgery and survived for 4.5 years after his HCC was diagnosed.

Therapeutic effects of sleeve gastrectomy for non-alcoholic steatohepatitis estimated by paired liver biopsy in morbidly obese Japanese patients.

ABSTRACT: Bariatric surgery has been reported to improve non-alcoholic steatohepatitis (NASH), which is a frequent comorbidity in morbidly obese patients. We performed a retrospective cohort study to estimate the therapeutic effect of sleeve gastrectomy (SG), the most common bariatric surgery in Japan, on obese patients with NASH by comparing the findings of paired liver biopsies.Eleven patients who underwent laparoscopic SG for the treatment of morbid obesity, defined as body mass index (BMI) > 35 kg/m2, from March 2015 to June 2019 at Hiroshima University Hospital, Japan, were enrolled. All patients were diagnosed with NASH by liver biopsy before or during SG and were re-examined with a second liver biopsy 1 year after SG. The clinical and histological characteristics were retrospectively analyzed.One year after SG, body weight and BMI were significantly reduced, with median reductions in body weight and BMI of-22 kg and -7.9 kg/m2, respectively. Body fat was also significantly reduced at a median of 13.7%. Liver-related enzymes were also significantly improved. On re-examination by paired liver biopsy, liver steatosis improved in 9 of the 11 patients (81.8%), ruling out of the pathological diagnosis of NASH. However, fibrosis stage did not significantly improve 1 year after SG. The non-alcoholic fatty liver disease activity score was significantly reduced in 10 of 11 patients (90.9%).Pathological improvement or remission of NASH could be achieved in most morbidly obese Japanese patients 1 year after SG.

Iatrogenic hepatic granuloma (suspected liver metastatic lesion on imaging) caused by liver retraction during laparoscopic gastrectomy: A case report.

There are no previous reports of hepatic granuloma secondary to intraoperative liver retraction. Using softer hepatic retraction instruments and keeping hepatic retraction time to a minimum are vital in preventing postoperative liver damage.

Perioperative management of polycythemia vera with advanced gastric cancer: A case report.

INTRODUCTION: Polycythemia vera (PV) is a chronic myeloproliferative disorder with generally good prognosis. However, thrombotic and cardiovascular complications are among the leading causes of death in patients with PV and sufficiently effective management strategies are yet to be established. We report a case involving operation for gastric cancer in a patient being treated for PV. PRESENTATION OF CASE: A 73-year-old man was diagnosed as PV on the basis of abnormal laboratory data eight years previously. Three months ago, he was referred to our department for anorexia and melena. The preoperative diagnosis was advanced gastric cancer, Stage IIB. To avoid perioperative thrombotic and hemorrhagic events, low-dose aspirin administration was continued with an additional dose of hydroxyurea. Emergent control was necessary because of the severity of gastric cancer symptoms, including pyloric stenosis and anemia. Distal gastrectomy with D2 lymph node resection was performed. The postoperative course was satisfactory, and the patient is currently doing well without any signs of recurrence or hematological complications. DISCUSSION: We described the successful management of a patient being treated for PV who underwent gastrectomy. As mentioned earlier, thrombotic complications and hemorrhage during the perioperative period are the major risk factors in patients with PV. In this case, control of white blood cell and platelet counts during the perioperative period led to good results. CONCLUSIONS: Perioperative management for PV is important for complication-free surgery. Careful follow up should be performed for gastric cancer and PV recurrence.

Cotransplantation of preactivated mesenchymal stem cells improves intraportal engraftment of islets by inhibiting liver natural killer cells in mice.

The activation of natural killer (NK) cells in the liver inhibits engraftment of intraportally transplanted islets. We attempted to modulate the activity of NK cells by cotransplanting mesenchymal stem cells (MSCs) with islets in mice. We first investigated the ability of MSCs to secrete prostaglandin E2 , a predominant inhibitor of NK cell function, in various combinations of inflammatory cytokines. Notably, we found that prostaglandin E2 production was partially delayed in MSCs activated by inflammatory cytokines in vitro, whereas liver NK cells were activated early after islet transplant in vivo. Accordingly, preactivated MSCs, but not naive MSCs, substantially suppressed the expression of activation markers in liver NK cells after cotransplant with islets. Similarly, cotransplant with preactivated MSCs, but not naive MSCs, markedly improved the survival of islet grafts. These results highlight MSC cotransplant as an effective and clinically feasible method for enhancing engraftment efficiency.

Effect of bevacizumab plus XELOX (CapeOX) chemotherapy on liver natural killer cell activity in colorectal cancer with resectable liver metastasis.

AIM: We investigated the chemotherapy effect of resectable colorectal cancer with liver metastasis (CRLM) on the function of intrahepatic immune cells. METHODS: We classified patients into adjuvant chemotherapy (bevacizumab+CapeOX) after hepatectomy group (group A) and neoadjuvant chemotherapy followed by hepatectomy group (group B), and collected peripheral blood mononuclear cells (PBMC) and liver mononuclear cells (LMNC) to ascertain phenotypic and functional differences. RESULTS: There were no significant differences in lymphocyte fractions of either PBMC or LMNC between groups, except for the significantly lower percentage of natural killer (NK) cells in LMNC in group B than in group A. Significantly higher percentage of natural-killer group 2, member D (NKG2D)- positive NK cells in PBMC and percentage of tumor necrosis factor-related apoptosis-inducing ligand (TRAIL)-, NKp30-, and signal regulatory protein ß (SIRPß)-positive NK cells in LMNC were found in group B. Furthermore, significantly higher expressions of NKG2D and SIRPß in peripheral blood NK cells and of NKp46 and CD122 in liver NK cells were found in group B. When LMNC were incubated with interleukin (IL)-2 in vitro, no difference was observed in the expression of these molecules in NK cells between groups. Consistently, there was no difference in the cytotoxic activity of those LMNC against a colon adenocarcinoma cell line between groups. CONCLUSION: Colorectal cancer with liver metastasis patients treated with neoadjuvant chemotherapy showed enhanced expression of activation markers on peripheral blood and liver NK cells in comparison with patients who did not receive therapy; however, the difference in those function remains unclear. These results suggest that neoadjuvant chemotherapy does not have a negative impact on intrahepatic immune cells in resectable CRLM patients.

Laparoscopic proximal gastrectomy with hinged double flap method using knotless barbed absorbable sutures: A case series.

BACKGROUND: Intracorporeal reconstruction following laparoscopic proximal gastrectomy is technically challenging. The aim of this study was to investigate the use of knotless barbed absorbable sutures in esophagogastrostomy closure using the hinged double flap method. DESIGN & METHOD: The subjects comprised patients with gastric cancer who were scheduled to undergo laparoscopic proximal gastrectomy. The V-Loc™ 180 wound closure device (V-Loc; Covidien, Mansfield, MA, USA) was used for all laparoscopic esophagogastrostomy closures. Between January 2015 and November 2016, 13 patients were enrolled. RESULTS: The mean suturing time was 109.6 min. Median hospital stay was 14 days. One anastomotic minor leakage occurred in an esophagogastrostomy and it was managed conservatively. Twelve of 13 patients did not exhibit any symptoms of reflux esophagitis. CONCLUSION: These results suggest the use of the unidirectional barbed absorbable suture is safe and produce reproducible results for esophagogastrostomy closure using the hinged double flap method.

Revascularization for cavernous transformation radical lymphadenectomy in the treatment of gastric cancer: A case report.

INTRODUCTION: There are few reported cases of cavernous transformation of the portal vein (CTPV). CTPV is usually found by accident because most patients are asymptomatic at presentation. This paper reports a case of early gastric cancer with CTPV that required gastrectomy and revascularization. PRESENTATION OF CASE: A 71-year-old man diagnosed with early gastric cancer, which was classified as clinical Stage IA (T1b, N0, M0) according to the TNM classification criteria for gastric cancer, was admitted to our hospital. Preoperative computed tomography (CT) revealed portal vein stenosis, CTPV, and esophageal varix. CT angiography showed that portal flow was maintained by the left gastric vein-right gastric vein (LGV-RGV) shunt. We had to perform lymphadenectomy while maintaining the hepatic blood flow. We performed distal gastrectomy with lymph node dissection including the vessel of the lesser curvature without massive bleeding. Postoperative course was uneventful, and CT examination performed in the 7th postoperative day revealed good blood flow from the reconstructed collateral vessels. The patient had no recurrence of gastric cancer during the postoperative period of 1 year. CONCLUSION: Diseases that cause intra-abdominal inflammation, such as pancreatitis and choledocholithiasis, might cause CTPV. Thus, patients with this medical history should be carefully assessed for CTPV to avoid intraoperative complications, such as massive bleeding or ischemia. When we preform operation a case with CTPV, we must pay meticulous attention. In our case, we encountered some difficulties in the surgical procedure, especially with respect to the dissection of the regional lymph nodes for gastric cancer.

Laparoscopic extra-abdominal suturing technique for the repair of Larrey's diaphragmatic hernia using the port closure needle (Endo Close®): A case report.

INTRODUCTION: Morgagni's or Larrey's diaphragmatic hernias are relatively uncommon. If the defect is too large for primary closure, the use of a mesh is inevitable. Although primary closure is adaptable for relatively small defects, it is difficult to suture the hernial orifice in which the anterior rim is absent. Herein, we present the case of a patient with Larrey's diaphragmatic hernia that was easily and securely repaired using the recently developed laparoscopic extra-abdominal suturing technique via the port closure needle (Endo Close®; Medtronic, Minneapolis, USA). PRESENTATION OF CASE: An 89-year-old woman complaining of vomiting was transferred to our hospital. Computed tomography scan showed Larrey's diaphragmatic hernia. Laparoscopic repair was performed after gastric decompression. We diagnosed Larrey's hernia on the left side of the falciform ligament. The transverse colon was herniated through the defect. Since the hernial defect was located below the substernal space, there was no tissue to stitch at the anterior rim of the hernial orifice. We performed the extra-abdominal suturing technique, suturing the posterior rim of the hernia to the full thickness of the anterior abdominal wall using the port closure needle (Endo Close®) without the need for a mesh. The patient was discharged on the 8th postoperative day. There was no evidence of recurrence at 8 months postoperatively. DISCUSSION: The recently developed extra-abdominal suturing technique using Endo Close® to suture the full thickness of the anterior abdominal wall achieved secure mattress suture and easy extra-abdominal tying. CONCLUSION: This method may be useful in terms of easiness and security of suture.

Fasting enhances TRAIL-mediated liver natural killer cell activity via HSP70 upregulation.

Acute starvation, which is frequently observed in clinical practice, sometimes augments the cytolytic activity of natural killer cells against neoplastic cells. In this study, we investigated the molecular mechanisms underlying the enhancement of natural killer cell function by fasting in mice. The total number of liver resident natural killer cells in a unit weight of liver tissue obtained from C57BL/6J mice did not change after a 3-day fast, while the proportions of tumor necrosis factor-related apoptosis-inducing ligand (TRAIL)+ and CD69+ natural killer cells were significantly elevated (n = 7, p <0.01), as determined by flow cytometric analysis. Furthermore, we found that TRAIL- natural killer cells that were adoptively transferred into Rag-2-/- γ chain-/- mice could convert into TRAIL+ natural killer cells in fasted mice at a higher proportion than in fed mice. Liver natural killer cells also showed high TRAIL-mediated antitumor function in response to 3-day fasting. Since these fasted mice highly expressed heat shock protein 70 (n = 7, p <0.05) in liver tissues, as determined by western blot, the role of this protein in natural killer cell activation was investigated. Treatment of liver lymphocytes with 50 µg/mL of recombinant heat shock protein 70 led to the upregulation of both TRAIL and CD69 in liver natural killer cells (n = 6, p <0.05). In addition, HSP70 neutralization by intraperitoneally injecting an anti- heat shock protein 70 monoclonal antibody into mice prior to fasting led to the downregulation of TRAIL expression (n = 6, p <0.05). These findings indicate that acute fasting enhances TRAIL-mediated liver natural killer cell activity against neoplastic cells through upregulation of heat shock protein 70.

Controlling the bleeding of jejunal varices formed at the site of choledochojejunostomy: report of 2 cases and a review of the literature.

INTRODUCTION: Hemorrhage from jejunal varices formed at the site of Roux-en-Y choledochojejunostomy is rather rare, and no guidelines have so far been established for its treatment. This report presents the cases of 2 patients with jejunal varices formed at the site of choledochojejunostomy that were treated using different methods. An obstruction of the extrahepatic portal vein resulted in massive gastrointestinal bleeding in both cases CASE 1: A 59-year-old male developed jejunal varices at the site of choledochojejunostomy. Multidetector computed tomography showed that the source of bleeding was located in the small intestine near portojejunal varices. The jejunal vein supplying the afferent loop was embolized using interventional radiology. There was no evidence of liver dysfunction or rebleeding after the embolization CASE 2: A 79-year-old female developed jejunal varices at the site of choledochojejunostomy. Abdominal angiography could not detect the source of bleeding, and hence, a mesocaval shunt operation was performed.