ABSTRACT
BACKGROUND: Clinical findings and postoperative follow-up data on remnant gastric cancer (RGC) are limited due to its rarity. Additionally, the preoperative staging, radical surgery, and managing recurrence in RGC present significant clinical challenges. METHODS: We analyzed the clinicopathological findings, adjuvant chemotherapy, and patterns of postoperative recurrence of 313 consecutive patients who underwent curative surgery for RGC at 17 Japanese institutions. This study investigated the optimal management of RGC and the impact of adjuvant chemotherapy (AC) on recurrence-free survival (RFS). RESULTS: Pathological stages I, II, and III were observed in 55.9% (N = 175), 24.9% (N = 78), and 19.2% (N = 60) of the patients, respectively. The overall concordance rate between clinical and pathological T staging was 58.3%, with a clinical T4 sensitivity of 41.4% for diagnosing pathological T4. During the median follow-up period of 4.6 years, disease recurrence occurred in 24.3% of patients. Most recurrences (over 80%) occurred within 2.5 years, and 96.1% within 5 years after RGC surgery. Peritoneal recurrence was the most common in patients with advanced RGC, accounting for 14.1% in stage II and 28.3% in stage III. Multivariable regression analysis showed that AC was significantly associated with a longer RFS, with a hazard ratio of 0.45 (95% confidence interval: 0.26-0.76). CONCLUSIONS: Our study underscores the importance of early detection, accurate preoperative staging, and postoperative surveillance in managing advanced RGC cases. Despite some limitations, our findings indicate that AC may provide survival benefits comparable to those seen in primary gastric cancer.
ABSTRACT
Low-grade appendiceal mucinous neoplasm (LAMN) is principally characterized by low-grade cytology without evidence of invasion to other organs. We report a LAMN surgical case whose appendiceal tumor penetrated the sigmoid colon wall. An 87-year-old man was referred for endoscopic resection (ER) of a colon polyp. Despite four ERs over 5 years, the polyp recurred at the same site. Laparoscopic surgery revealed a dilated appendix firmly attached to the sigmoid colon. We performed en bloc resection of both the sigmoid colon and appendix without tumor exposure. The histopathological evaluation showed that the LAMN had penetrated the sigmoid colon wall, forming two polyps on the colonic mucosa. In cases where the appendiceal-colonic fistula is suspected, en bloc resection of the appendix and colon wall should be considered.
Subject(s)
Adenocarcinoma, Mucinous , Appendiceal Neoplasms , Humans , Male , Appendiceal Neoplasms/pathology , Appendiceal Neoplasms/surgery , Appendiceal Neoplasms/diagnosis , Aged, 80 and over , Adenocarcinoma, Mucinous/surgery , Adenocarcinoma, Mucinous/pathology , Adenocarcinoma, Mucinous/diagnosis , Colon, Sigmoid/pathology , Colon, Sigmoid/surgery , Neoplasm InvasivenessABSTRACT
BACKGROUND: Body weight loss (BWL) after gastrectomy impact on the short- and long-term outcomes. Oral nutritional supplement (ONS) has potential to prevent BWL in patients after gastrectomy. However, there is no consistent evidence supporting the beneficial effects of ONS on BWL, muscle strength and health-related quality of life (HRQoL). This study aimed to evaluate the effects of ONS formulated primarily with carbohydrate and protein on BWL, muscle strength, and HRQoL. METHODS: This will be a multicenter, open-label, parallel, randomized controlled trial in patients with gastric cancer who will undergo gastrectomy. A total of 120 patients who will undergo gastrectomy will be randomly assigned to the ONS group or usual care (control) group in a 1:1 ratio. The stratification factors will be the clinical stage (I or ≥ II) and surgical procedures (total gastrectomy or other procedure). In the ONS group, the patients will receive 400 kcal (400 ml)/day of ONS from postoperative day 5 to 7, and the intervention will continue postoperatively for 8 weeks. The control group patients will be given a regular diet. The primary outcome will be the percentage of BWL (%BWL) from baseline to 8 weeks postoperatively. The secondary outcomes will be muscle strength (handgrip strength), HRQoL (EORTC QLQ-C30, QLQ-OG25, EQ-5D-5L), nutritional status (hemoglobin, lymphocyte count, albumin), and dietary intake. All analyses will be performed on an intention-to-treat basis. DISCUSSION: This study will provide evidence showing whether or not ONS with simple nutritional ingredients can improve patient adherence and HRQoL by reducing BWL after gastrectomy. If supported by the study results, nutritional support with simple nutrients will be recommended to patients after gastrectomy for gastric cancer. TRIAL REGISTRATION: jRCTs051230012; Japan Registry of Clinical Trails. Registered on Apr. 13, 2023.
Subject(s)
Dietary Supplements , Gastrectomy , Multicenter Studies as Topic , Quality of Life , Randomized Controlled Trials as Topic , Stomach Neoplasms , Humans , Stomach Neoplasms/surgery , Gastrectomy/adverse effects , Treatment Outcome , Weight Loss , Administration, Oral , Middle Aged , Male , Female , Adult , Aged , Nutritional Status , Time Factors , Hand Strength , Muscle StrengthABSTRACT
BACKGROUND: Esophageal diverticulum is commonly associated with esophageal motility disorders, which can be diagnosed using high-resolution manometry (HRM) according to the Chicago classification. Although midesophageal diverticulum (M-ED) is associated with inflammatory processes, esophageal motility disorders have been recently identified as an etiology of M-ED. CASE PRESENTATION: We present the case of a patient with M-ED and elevated intrabolus pressure (IBP), which did not meet the criteria for esophageal motility disorders according to the Chicago classification. A 71-year-old man presented with gradually worsening dysphagia for two years and was diagnosed as having an 8-cm-long M-ED and multiple small diverticula in lower esophagus. HRM revealed a median integrated relaxation pressure of 14.6 mmHg, a distal latency of 6.4 s, and an average maximum IBP of 35.7 mmHg. He underwent thoracoscopic resection of the M-ED and myotomy, which successfully alleviated the symptoms and reduced the intrabolus pressure to normal levels. CONCLUSIONS: It is important to recognize the esophageal diverticulum pathology with HRM findings even in cases where the results may not meet the Chicago classification and to include myotomy based on the results.
ABSTRACT
BACKGROUND: Even in cancer of unknown primary (CUP), which is rare clinical condition, solitary anterosuperior lymph node (LN) along the common hepatic artery (No.8a LN) enlargement diagnosed as metastatic adenocarcinoma has never been reported. CASE PRESENTATION: A 68-year-old Japanese male, with a history of early gastric cancer that had been completely treated by endoscopic submucosal dissection 26 years ago, was detected a single enlarged nodule along the common hepatic artery, No.8a LN, incidentally by computed tomography performed for monitoring of interstitial pneumonia. Endoscopic ultra-sound-guided fine needle aspiration revealed that this nodule was adenocarcinoma suggestive of metastasis, but other imaging studies, including upper and lower gastrointestinal endoscopy, positron emission tomography, and ultrasonography did not detect any primary cancer. We have finally diagnosed as the LN metastasis of CUP and performed laparoscopic lymphadenectomy for this tumor. The tumor was approximately 5 cm in size, was in close proximity to the pancreas, and involved part of the right gastric artery and vein. LNs in the No.5 and No.8a areas, including this tumor, were dissected laparoscopically, and radical resection was achieved. The patient had no postoperative complication and was discharged on postoperative day 10. Immunohistopathological findings revealed that the tumor was poorly differentiated adenocarcinoma, and different from the histology of gastric cancer resected 26 years ago, although the tumor was suggestive of gastrointestinal origin. Imaging studies performed 2 and 6 months after discharge also did not reveal a primary site. CONCLUSION: We reported a case of solitary No.8a LN adenocarcinoma of CUP. For diagnostic and therapeutic purposes, radical resection is recommended for single enlarged intra-abdominal LN of CUP.
ABSTRACT
Laparoscopic complete mesocolic excision with central vessel ligation has been widely accepted for its oncological benefits in colon cancer surgery. However, laparoscopic right hemicolectomy involves a risk for vascular injury during dissection around the surgical trunk. This technical difficulty has been attributed to the limited movement of conventional laparoscopic forceps. Although robotic devices can overcome the restricted motion of laparoscopic devices, they are not yet widely used. The ArtiSential is an articulating laparoscopic instrument that has a two-joint end-effector that enables a wide range of motion precisely reflecting the surgeon's finger movements, and is designed to compensate for the drawbacks of conventional laparoscopic tools. The present study demonstrated the utility of articulating instruments in laparoscopic right hemicolectomy by comparing the authors' laparoscopic procedures, using articulating instruments, with robotic procedures. Articulating laparoscopic instruments can be successfully maneuvered in virtually the same manner as robotic devices and, as such, represent a viable alternative to robotic surgery. Supplementary Information: The online version contains supplementary material available at 10.1007/s13691-024-00654-w.
ABSTRACT
Approximately 10% of gastrointestinal stromal tumors (GISTs) harbor reportedly no KIT and PDGFRA mutations (wild-type GISTs). The clinicopathological features and oncologic outcomes of wild-type GISTs based on molecular profiles are unknown. We recruited 35 wild-type GIST patients from the two registry studies of high-risk GISTs between 2012 and 2015 and primary GISTs between 2003 and 2014. Molecular profiling of wild-type GISTs was performed by targeted next-generation sequencing (NGS) using formalin-fixed paraffin-embedded tumor samples. Among 35 wild-type GISTs, targeted NGS analysis detected NF1, SDH, or BRAF mutation: 16 NF1-GISTs with various NF1 mutations, 12 SDH-GISTs (4 with SDHA mutations, 4 with SDHB mutations, and 4 with SDHB-negative staining), and 5 BRAF-GISTs with the V600E mutation. Two GISTs showed no mutations based on our targeted NGS analysis. Additional gene mutations were infrequent in primary wild-type GISTs and found in TP53, CREBBP, CDKN2A, and CHEK2. Most NF1-GISTs were located in the small intestine (N = 12; 75%) and showed spindle cell features (N = 15; 94%) and multiple tumors (N = 6, 38%) with modest proliferation activities. In contrast, SDH-GISTs were predominantly found in the stomach (N = 11; 92%), exhibiting epithelioid cell (N = 6; 50%) and multiple (N = 6, 50%) features. The overall survival of patients with SDH-GISTs appeared to be better than that of BRAF-GISTs (p = 0.0107) or NF1-GISTs (p = 0.0754), respectively. In conclusion, major molecular changes in wild-type GISTs include NF1, SDH, and BRAF. NF1-GISTs involved multifocal spindle cell tumors in the small intestine. SDH-GISTs occurred in young patients and were multifocal in the stomach and clinically indolent.
Subject(s)
Gastrointestinal Stromal Tumors , Humans , Gastrointestinal Stromal Tumors/genetics , Gastrointestinal Stromal Tumors/pathology , Mutation , Proto-Oncogene Proteins B-raf/genetics , Proto-Oncogene Proteins c-kit/genetics , Proto-Oncogene Proteins c-kit/metabolism , Receptor Protein-Tyrosine Kinases/genetics , Receptor, Platelet-Derived Growth Factor alpha/genetics , Succinate Dehydrogenase/geneticsABSTRACT
The coronavirus disease 2019 pandemic affected cancer surgeries and advanced cancer diagnoses; however, the trends in patient characteristics in medical institutions during this time, and the surgical approaches used are unclear. We investigated the impact of the pandemic on gastric and colorectal cancer surgeries in the Kinki region of Japan. We grouped 1688 gastric and 3493 colorectal cancer surgeries into three periods: "pre-pandemic" (April 2019-March 2020), "pandemic 1" (April 2020-March 2021), and "pandemic 2" (April 2021-September 2021), to investigate changes in the number of surgeries, patient characteristics, surgical approaches, and cancer progression after surgery. Gastric and colorectal cancer surgeries decreased from the pre-pandemic levels, by 20% and 4%, respectively, in pandemic 1, and by 31% and 19%, respectively, in pandemic 2. This decrease had not recovered to pre-pandemic levels by September, 2021. Patient characteristics, surgical approaches, and cancer progression of gastric and colorectal surgeries did not change remarkably as a result of the coronavirus disease 2019 pandemic.
Subject(s)
COVID-19 , Colorectal Neoplasms , Humans , Japan/epidemiology , Pandemics , COVID-19/epidemiology , Epidemiologic Studies , Colorectal Neoplasms/epidemiology , Colorectal Neoplasms/surgeryABSTRACT
PURPOSE: Loss of skeletal muscle mass after gastrectomy for gastric cancer leads to decreased quality of life and poor postoperative survival. However, few studies have examined the postoperative loss of skeletal muscle mass following minimally invasive gastrectomy. This study investigated the impact of minimally invasive total gastrectomy (MI-TG) on changes in skeletal muscle mass during the early postoperative period. METHODS: Patients who underwent MI-TG or minimally invasive distal or proximal gastrectomy (MI-nonTG) for cStage I-III gastric cancer were retrospectively analyzed (n = 58 vs. 182). Their body composition was measured before surgery and 2 months after surgery. Multivariable linear regression analysis was performed to clarify the impact of the surgical procedure on skeletal muscle index changes using clinically relevant covariates. RESULTS: Skeletal muscle mass decreased more in the MI-TG group than in the MI-nonTG group (median [interquartile range]; -5.9% [-10.6, -3.7] vs -4.5% [-7.3, -1.9], P = 0.004). In multivariable linear regression analysis using clinically relevant covariates, MI-TG was an independent risk factor for postoperative loss of skeletal muscle mass (coefficient - 2.6%, 95% CI -4.5 to -0.68, P = 0.008). CONCLUSIONS: Total gastrectomy was a risk factor for loss of skeletal muscle mass during the early postoperative period. If oncologically feasible, proximal or distal gastrectomy with a small remnant stomach should be considered.
Subject(s)
Stomach Neoplasms , Humans , Stomach Neoplasms/complications , Retrospective Studies , Quality of Life , Gastrectomy/adverse effects , Gastrectomy/methods , Risk Factors , Muscle, Skeletal , Minimally Invasive Surgical Procedures/adverse effects , Minimally Invasive Surgical Procedures/methods , Postoperative Period , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Postoperative Complications/surgeryABSTRACT
BACKGROUND: Robotic gastrectomy (RG) using the da Vinci Surgical System for gastric cancer was approved for national medical insurance coverage in Japan in April 2018, and its number has been rapidly increasing since then. AIM: We reviewed and compared current evidence on RG and conventional laparoscopic gastrectomy (LG) to identify the differences in surgical outcomes. METHODS: Three independent reviewers systematically reviewed the data collected from a comprehensive literature search by an independent organization, focusing on the following nine endpoints: mortality, morbidity, operative time, estimated blood loss volume, length of postoperative hospital stay, long-term oncologic outcome, quality of life, learning curve, and cost. RESULTS: Compared to LG, RG has lower intraoperative blood loss volume, shorter length of hospital stay, and shorter learning curve, but both procedures have similar mortality. Contrarily, its disadvantages include longer procedural time and higher costs. Although the morbidity rate and long-term outcomes are almost comparable, RG showed superior potentials. Currently, the outcomes of RG are considered comparable to or better than LG. CONCLUSION: RG might be applicable to all gastric cancer patients who fulfill the indication of LG at institutions that meet specific criteria and are approved to claim the National Health Insurance costs for the use of the surgical robot in Japan.
Subject(s)
Laparoscopy , Robotic Surgical Procedures , Robotics , Stomach Neoplasms , Humans , Robotics/methods , Robotic Surgical Procedures/methods , Stomach Neoplasms/surgery , Quality of Life , Treatment Outcome , Gastrectomy/methods , Laparoscopy/methods , Postoperative Complications/epidemiology , Postoperative Complications/surgery , Retrospective StudiesABSTRACT
A 47-year-old man underwent low anterior resection for rectal cancer and was surveilled for 5 years without metastasis. Twenty-four years later, the patient developed an implantation cyst at the anastomotic site. Two years after the diagnosis, colonoscopy revealed a disintegrated area in the lesion, and pathological examination of the biopsy specimen revealed adenocarcinoma. Due to the suspicion of invasion into the surrounding organs, the patient underwent laparoscopic total pelvic exenteration after neoadjuvant chemoradiotherapy. A transabdominal and transperineal endoscopic approach was used for safe en bloc excision of the tumor. Pathological examination of the specimen confirmed mucinous adenocarcinoma arising from the implantation cyst. Although an implantation cyst is considered benign, it is important to suspect malignant transformation when its appearance changes. For the accurate diagnosis of implantation cysts, surgeons, endoscopists, and radiologists should be aware of this disease.
Subject(s)
Adenocarcinoma, Mucinous , Adenocarcinoma , Cysts , Pelvic Exenteration , Rectal Neoplasms , Male , Humans , Middle Aged , Pelvic Exenteration/methods , Rectal Neoplasms/surgery , Rectal Neoplasms/pathology , Adenocarcinoma/surgery , Adenocarcinoma/pathology , Cysts/surgery , Adenocarcinoma, Mucinous/surgeryABSTRACT
BACKGROUND: Despite growing evidence of the effectiveness of minimally invasive surgery (MIS) for primary gastric cancer, MIS for remnant gastric cancer (RGC) remains controversial due to the rarity of the disease. This study aimed to evaluate the surgical and oncological outcomes of MIS for radical resection of RGC. PATIENTS AND METHODS: Patients with RGC who underwent surgery between 2005 and 2020 at 17 institutions were included, and a propensity score matching analysis was performed to compare the short- and long-term outcomes of MIS with open surgery. RESULTS: A total of 327 patients were included in this study and 186 patients were analyzed after matching. The risk ratios for overall and severe complications were 0.76 [95% confidence interval (CI): 0.45, 1.27] and 0.65 (95% CI: 0.32, 1.29), respectively. The MIS group had significantly less blood loss [mean difference (MD), -409 mL; 95% CI: -538, -281] and a shorter hospital stay (MD, -6.5 days; 95% CI: -13.1, 0.1) than the open surgery group. The median follow-up duration of this cohort was 4.6 years, and the 3-year overall survival were 77.9% and 76.2% in the MIS and open surgery groups, respectively [hazard ratio (HR), 0.78; 95% CI: 0.45, 1.36]. The 3-year relapse-free survival were 71.9% and 62.2% in the MIS and open surgery groups, respectively (HR, 0.71; 95% CI: 0.44, 1.16). CONCLUSIONS: MIS for RGC showed favorable short- and long-term outcomes compared to open surgery. MIS is a promising option for radical surgery for RGC.
Subject(s)
Stomach Neoplasms , Humans , Retrospective Studies , Stomach Neoplasms/surgery , Neoplasm Recurrence, Local/surgery , Cohort Studies , Minimally Invasive Surgical Procedures , Length of Stay , Treatment OutcomeABSTRACT
BACKGROUND: Oncological benefits of robotic gastrectomy (RG) remain unclear. We aimed to determine and compare the 3-year outcomes of RG and laparoscopic gastrectomy (LG) for the treatment of gastric cancer. METHODS: This was a multi-institutional retrospective study of patients who prospectively underwent RG in a previous study (UMIN000015388) and historical controls who underwent LG. Operable patients with cStage I/II primary gastric cancer were enrolled. The inverse probability of treatment weighting method based on propensity scores was used to balance patient demographic factors and surgeon volume between the RG and LG groups. The primary outcome measure was the 3-year overall survival rate (3yOS). RESULTS: Of the 1,127 patients in the previous study, 326 and 752 patients in the RG and LG groups, respectively, completed the study. The standardized difference of all confounding factors was reduced to 0.09 or less after weighting. In the weighted population, 3yOS was 96.3% and 89.6% in the RG and LG groups, respectively (hazard ratio [HR] 0.34 [0.15, 0.76]; p = 0.009), whereas there was no difference in 3-year recurrence-free survival rate (3yRFS) between the two groups (HR 0.58 [0.32, 1.05]; p = 0.073). Sub-analyses showed that RG improved 3yOS (HR 0.05 [0.01, 0.38]; p = 0.004) and 3yRFS (HR 0.05 [0.01, 0.34]; p = 0.003) in patients with pStage IA disease. Recurrence rates and patterns were similar between the RG and LG groups. RG did not improve the morbidity rate, however, it attenuated some of the adverse events, including anastomotic leakage and intra-abdominal abscess. RG improved estimated blood loss and duration of postoperative hospitalization. CONCLUSION: This study showed surgical and oncological safety of RG for cStage I/II gastric cancer considering the 3-year outcomes, compared with those of LG.
Subject(s)
Laparoscopy , Robotic Surgical Procedures , Stomach Neoplasms , Humans , Stomach Neoplasms/surgery , Retrospective Studies , Gastrectomy , Propensity ScoreABSTRACT
Erythropoietic protoporphyria (EPP) is a rare hereditary subtype of cutaneous porphyria characterized by photosensitivity. Increased exposure to light irradiation may precipitate acute liver failure, and surgical light-induced intestinal burns and perforations are known to occur. We report a case of EPP in a patient who underwent laparoscopic partial cecectomy for appendiceal mucocele. A 55-year-old man with EPP was presented for treatment of appendiceal mucocele. A light test using two types of laparoscopes (Companies O and S) was performed preoperatively. Light from the laparoscope manufactured by Company O caused photosensitivity; this effect was not observed with light from the laparoscope manufactured by Company S. Therefore, we performed laparoscopic partial cecectomy through a single umbilical incision using the laparoscope from Company S. Except for the incision site, the patient's skin was completely covered using surgical drapes. No intra- or postoperative complications were observed. Histopathological examination of the resected specimen revealed a low-grade appendiceal mucinous neoplasm.
Subject(s)
Appendiceal Neoplasms , Laparoscopy , Mucocele , Porphyrias , Male , Humans , Middle Aged , Mucocele/complications , Mucocele/surgery , Laparoscopy/adverse effects , Appendectomy/adverse effects , Porphyrias/complications , Porphyrias/surgeryABSTRACT
BACKGROUND/AIM: Total gastrectomy with splenectomy (TGS) is routinely performed in patients with type 4 or large type 3 gastric cancer (GC), which sometimes metastasize to splenic hilar lymph nodes (LNs). However, the indication for and significance of TGS remain controversial. This multicenter retrospective study aimed to evaluate the oncological feasibility of laparoscopic TGS (LTGS) in patients with advanced proximal GC. PATIENTS AND METHODS: We retrospectively studied patients with type 4 or large type 3 GC who underwent LTGS at three Institutes between January 2010 and December 2018. RESULTS: We identified 26 consecutive eligible patients for analysis. Large type 3/type 4 were observed in 10 (38.5%)/16 (61.5%) cases. Involvement of the greater curvature was observed in 19 cases (73.1%), and GC spread to the whole stomach was observed in 12 cases (46.2%). R0 resection was achieved in 23 cases (88.5%). The median number of retrieved splenic hilar LNs was 4.0 (1-15), and the number of cases with splenic hilar LN metastasis was 3 (11.5%). Postoperative grade II intra-abdominal abscess was observed in 1 case (3.8%), and pancreatic fistula was not observed in any patient. Recurrence was observed in 18 cases (69.2%), of which 16 (88.9%) presented peritoneal recurrence. The median overall survival (OS) was 40.6 months, and the 5-year OS rate was 30.3%. The 5-year survival rate of patients with splenic hilar LN metastasis was 33.3% and the therapeutic value of splenectomy was 3.83. CONCLUSION: LTGS was performed safely, but the oncological benefit of the procedure for type 4 or large type 3 GC was very limited.
Subject(s)
Laparoscopy , Neoplasms, Second Primary , Splenic Neoplasms , Stomach Neoplasms , Humans , Stomach Neoplasms/surgery , Splenectomy , Retrospective Studies , Gastrectomy/adverse effects , Postoperative Complications , Laparoscopy/adverse effectsABSTRACT
BACKGROUND: The treatment strategy for metastatic lesions of primary malignant melanoma of the esophagus (PMME) is currently determined on a case-by-case basis, based on the National Comprehensive Cancer Network (NCCN) guidelines for cutaneous melanoma. The NCCN guidelines state that resection should be considered in patients with resectable metastatic recurrence. Herein, we report a case of long-term survival treated with three metastasectomies and two subsequent adjuvant nivolumab therapies for the metastatic recurrence of PMME. CASE PRESENTATION: A 65-year-old female patient with PMME underwent thoracoscopic subtotal esophagectomy, gastric tube reconstruction via the posterior mediastinal route, and cervical esophagogastric anastomosis. Histopathological examination of the resected specimen revealed that the tumor was PMME with tumor invasion into the muscularis propria and no lymph node metastasis. At the age of 68 years, she developed intestinal invagination due to jejunal metastasis of malignant melanoma and underwent resection of the jejunum. Histopathological examination of the resected specimen revealed two metastases of malignant melanoma in the jejunum and one metastasis to the mesenteric lymph node. At the age of 75 years, a recurrence of malignant melanoma was found in the cervical esophagus. She underwent thoracoscopic mobilization of the gastric tube and esophagus followed by cervical esophagectomy and reconstruction with a free jejunum flap. She received 24 courses of nivolumab therapy for 1 year as a postoperative adjuvant therapy. Subsequently, at the age of 78 years, an enlarged left cervical lymph node and a mass in the right lower lobe of the lung were found. She underwent left cervical lymph node dissection and thoracoscopic wedge resection of the right lung. Histopathological examination of the resected specimens revealed that both tumors were metastases of malignant melanoma. At age 79 years, she received eight courses of nivolumab therapy as a second postoperative adjuvant therapy, with no sign of recurrence in a 9-month follow-up period after the third metastasectomy. CONCLUSION: In cases of metastatic recurrence of PMME, aggressive resection of oligometastasis with postoperative adjuvant nivolumab therapy may result in long-term survival.
ABSTRACT
BACKGROUND: The safety of robotic gastrectomy (RG) for gastric cancer in daily clinical settings and the process by which surgeons are introduced and taught RG remain unclear. This study aimed to evaluate the safety of RG in daily clinical practice and assess the learning process in surgeons introduced to RG. METHODS: Patients who underwent RG for gastric cancer at Kyoto University and 12 affiliated hospitals across Japan from January 2017 to October 2019 were included. Any morbidity with a Clavien-Dindo classification grade of II or higher was evaluated. Moreover, the influence of the surgeon's accumulated RG experience on surgical outcomes and surgeon-reported postoperative fatigue were assessed. RESULTS: A total of 336 patients were included in this study. No conversion to open or laparoscopic surgery and no in-hospital mortality were observed. Overall, 50 (14.9%) patients developed morbidity. During the study period, 14 surgeons were introduced to robotic procedures. The initial five cases had surprisingly lower incidence of morbidity compared to the following cases (odds ratio 0.29), although their operative time was longer (+ 74.2 min) and surgeon's fatigue scores were higher (+ 18.4 out of 100 in visual analog scale). CONCLUSIONS: RG was safely performed in actual clinical settings. Although the initial case series had longer operative time and promoted greater levels of surgeon fatigue compared to subsequent cases, our results suggested that RG had been introduced safely.
Subject(s)
Laparoscopy , Robotic Surgical Procedures , Stomach Neoplasms , Cohort Studies , Gastrectomy/adverse effects , Gastrectomy/methods , Humans , Laparoscopy/adverse effects , Laparoscopy/methods , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Postoperative Complications/surgery , Retrospective Studies , Robotic Surgical Procedures/adverse effects , Robotic Surgical Procedures/methods , Treatment OutcomeABSTRACT
BACKGROUND: MicroRNAs (miRNAs) are key regulators of stem cell functions, including self-renewal and differentiation. In this study, we aimed to identify miRNAs that are upregulated during terminal differentiation in the human colon epithelium, and elucidate their role in the mechanistic control of stem cell properties. METHODS: "Bottom-of-the-crypt" (EPCAM+/CD44+/CD66alow) and "top-of-the-crypt" (EPCAM+/CD44neg/CD66ahigh) epithelial cells from 8 primary colon specimens (6 human, 2 murine) were purified by flow cytometry and analyzed for differential expression of 335 miRNAs. The miRNAs displaying the highest upregulation in "top-of-the-crypt" (terminally differentiated) epithelial cells were tested for positive correlation and association with survival outcomes in a colon cancer RNA-seq database (n = 439 patients). The two miRNAs with the strongest "top-of-the-crypt" expression profile were evaluated for capacity to downregulate self-renewal effectors and inhibit in vitro proliferation of colon cancer cells, in vitro organoid formation by normal colon epithelial cells and in vivo tumorigenicity by patient-derived xenografts (PDX). RESULTS: Six miRNAs (miR-200a, miR-200b, miR-200c, miR-203, miR-210, miR-345) were upregulated in "top-of-the-crypt" cells and positively correlated in expression among colon carcinomas. Overexpression of the three miRNAs with the highest inter-correlation coefficients (miR-200a, miR-200b, miR-200c) associated with improved survival. The top two over-expressed miRNAs (miR-200c, miR-203) cooperated synergistically in suppressing expression of BMI1, a key regulator of self-renewal in stem cell populations, and in inhibiting proliferation, organoid-formation and tumorigenicity of colon epithelial cells. CONCLUSION: In the colon epithelium, terminal differentiation associates with the coordinated upregulation of miR-200c and miR-203, which cooperate to suppress BMI1 and disable the expansion capacity of epithelial cells.
Subject(s)
Colonic Neoplasms , MicroRNAs , Animals , Cell Line, Tumor , Colonic Neoplasms/genetics , Epithelial Cell Adhesion Molecule/metabolism , Epithelial Cells/metabolism , Gene Expression Regulation, Neoplastic , Humans , Mice , MicroRNAs/genetics , Polycomb Repressive Complex 1/genetics , Polycomb Repressive Complex 1/metabolism , Proto-Oncogene Proteins , Up-RegulationABSTRACT
BACKGROUND: Routine placement of a feeding jejunostomy tube (FJT) following esophagectomy remains controversial due to the risk of complications including small bowel obstruction (SBO). This study aimed to evaluate FJT placement following esophagectomy. METHODS: This retrospective cohort study included consecutive 229 patients undergoing thoracoscopic esophagectomy between January 2010 and June 2020. Short-term outcomes, postoperative nutritional status, incidence of SBO, and long-term outcomes were compared between patients according to FJT placement. RESULTS: The total operative duration was significantly longer in the FJT group compared to the no FJT group (P < 0.0001); however, no differences in overall or severe postoperative morbidity were observed. Body weight loss at discharge was significantly attenuated in patients with FJT (5% vs 7%, P = 0.001). Serum cholinesterase levels were significantly higher in patients with FJT (P = 0.002), while no difference was observed in serum albumin levels. At 6-month follow-up, no statistically significant differences were observed in serological markers or percentage body weight. The incidence of SBO was significantly higher in the FJT group (P = 0.006). The 5-year incidence of SBO was 12%. Patients in the FJT group had higher progression-free and overall survival compared to patients in the no FJT group (P = 0.041 and P = 0.033, respectively). A similar trend toward better survival in the FJT group was observed after propensity score matching. CONCLUSIONS: Routine placement of FJT significantly improves postoperative nutritional status and may contribute to improved long-term survival but is associated with increased long-term risk of SBO.