Successful perioperative management of a patient with idiopathic thrombocytopenic purpura undergoing emergent appendectomy: Report of a case.

INTRODUCTION: Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disease characterized by a low platelet count and normal bone marrow. Patients with ITP undergoing surgery are thought to have increased risk for postoperative complications because of their thrombocytopenia. PRESENTATION OF CASE: we report the case of a 66-year-old woman with ITP who required an emergency operation for acute appendicitis associated with disseminated intravascular coagulation. Preoperative therapy consisted of platelet transfusions only, and intraoperative hemostasis was achieved. Postoperatively, high-dose intravenous immunoglobulin (IVIg) therapy led to an increased, stable, and adequate platelet count and good hemostasis. DISCUSSION: The outcome of this case suggests that IVIg therapy is not always required for preoperative management of patients with. CONCLUSION: IVIg therapy may be useful for postoperative management after emergency surgery.

Radical endoscopic resection is unsuitable for most synchronous, multiple and early gastric cancers.

BACKGROUND/AIMS: It remains unclear whether synchronous, multiple, early gastric cancers can be radically resected with endoscopic resection. METHODOLOGY: Patients who underwent gastrectomy for early gastric cancer were included in this study and divided into two groups: a solitary gastric cancer group and a multiple gastric cancer group. The clinicopathological features of patients in each group were compared and the criteria for endoscopic resection were subsequently investigated. RESULTS: A total of 244 patients were included in the present study. The solitary and multiple gastric cancer groups included 228 patients (93.4%) and 16 patients (6.6%), respectively. The multiple gastric cancer group included 35 lesions, including a greater number of larger tumors and protruded- type tumors, as well as increased incidence of submucosal and lymphatic invasion. Only 2 of 16 cases (12.5%) in the multiple gastric cancer group met the criteria for endoscopic resection. Eleven cases were excluded due to submucosal invasion and three cases were excluded due to undifferentiated histopathological type tumors. CONCLUSIONS: To be suitable for radical endoscopic resection, prompt detection of early gastric cancer is essential, before they become multiple gastric cancers and invade the submucosa.

How should we treat gastric cancer in the very elderly?

BACKGROUND/AIMS: We aimed to clarify the clinicopathological features of gastric cancer in very elderly patients and to identify appropriate surgical therapy for them, focused particularly on their prognosis. METHODOLOGY: Patients who underwent gastrectomy for gastric cancer in Oita University Hospital were included in this study. The patients were divided into two groups: the very elderly group (80 years or older) (E group) and the middle-aged group (ranging from 40 to 79 years) (M group). Their clinicopathological features and postoperative survival were compared. RESULTS: Type 3,4 macroscopic types, INFγ and number of dissected lymph nodes were significantly less in the E group than in the M group (p=0.0092, p=0.0077, p=0.0475, respectively). Overall survival and disease-free survival were shorter for the E group (p=0.0898, p=0.0566, respectively). When other cause-related deaths were considered to be lost to follow-up, there was no significant difference between the E group and the M group. CONCLUSIONS: Whenever radical resection is possible, surgical resection for gastric cancer, even in the very elderly, should not be denied. Nevertheless, surgeons should try to do less invasive surgery, especially for the very elderly.

Multivariate evaluation of the technical difficulties in performing laparoscopic anterior resection for rectal cancer.

BACKGROUND: Although the laparoscopic approach is accepted for the treatment of colon cancer, its value for low rectal cancer is unknown. We sought to evaluate the technical feasibility of laparoscopic low anterior resection (Lap-AR) by determining short-term clinical outcomes and identifying the corresponding predictive factors. METHODS: A retrospective single-institution study was carried out on 82 patients in whom Lap-AR had been attempted for rectal cancer during the period spanning April 2001 to December 2009. Patient characteristics, operative outcomes, and postoperative morbidities and mortalities were analyzed. RESULTS: The median operative time and the intraoperative blood loss were 300 minutes and 72.5 g, respectively. Overall morbidity and mortality rates were 11.0% and 0%, respectively. Complications included wound infection (6.1%, n=5), anastomotic leakage (1.2%, n=1), ileus (1.2%, n=1), and pneumonia (2.4%, n=2). A multivariate analysis indicated that the important risk factor associated with an operative time of >300 minutes was the T factor, and the risk factor associated with intraoperative blood loss was a body mass index (BMI) of >25 kg/m(2). CONCLUSIONS: Lap-AR is a technically feasible, safe, and effective method for treating patients with rectal cancer. A BMI>25 kg/m(2) and the T factor related to operative blood loss and operative time, respectively. Assessment of high BMI and, in particular, advanced tumor depth, should alert surgeons to the increased technical difficulty of Lap-AR.

[Complete response in an elderly patient with advanced gastric cancer treated with TS-1].

The patient was an 80-year-old man whose complaint was coffee-grounds vomit. He was diagnosed with advanced gastric cancer, T2N1H0P0M0, stage II. Though the curative operation was explained to the patient, he declined it because of complications of advanced age, diabetes and bronchial asthma; chemotherapy was chosen instead. TS-1 (80 mg/day) was administered for 28 days, followed by 14 days rest as one course. A partial response was observed after the first course, and no cancer cells were confirmed by endoscopic biopsy after the fifth course. Moreover, after the 14th course, CT showed a complete regression of lymph node metastasis, and no cancer cells were confirmed by endoscopic biopsy, for a complete response (CR). From now on, as society grays more and more, it is considered that elderly advanced gastric cancer patients with complications will increase. TS-1 single treatment is considered to be safe and outpatient treatment possible as one of the useful cures.

Is a metallic stent useful for non resectable esophageal cancer?

A flexible nitinol stent was inserted to treat malignant stricture of the esophagus in 28 patients. Stenting was successful in all 28 patients, leading to an improved oral intake that was maintained for >80% of the survival period in 26 patients. Patients with tumors arising in the esophagus (n=24) were divided into two groups to compare complications and prognosis: patients who underwent stenting only (n=10); and patients who underwent stenting after radiochemotherapy (n=14). Fatal complications associated with stenting were seen in four patients (28.6%) who underwent stenting after radiochemotherapy and in one patient (10.0%) who underwent stenting only. Although survival was significantly longer for patients who underwent prior radiochemotherapy than for patients who did not, the incidence of fatal complications tended to be higher. No significant differences in background factors other than radiochemotherapy before stenting were observed between patients with fatal and non-fatal complications. Stenting was shown to represent a useful treatment for malignant stricture of the esophagus, as oral intake improved and was maintained for a long period of time in most patients. However, incidence of fatal complications was high among patients who underwent radiochemotherapy, and caution must be exercised due to the difficulty in predicting fatal complications.

Repair of ileal conduit parastomal hernia by translocation of the stoma.

We repaired a recurrent ileal conduit parastomal hernia, according to Kaufman's technique, by translocating the stoma to the opposite side of the abdominal wall without laparotomy. This procedure is a simple and less invasive treatment for large parastomal hernia.

Lymph node metastasis could be predicted by evaluation of macrophage infiltration and hsp70 expression in superficial carcinoma of the esophagus.

Macrophages have been reported to play an important role in suppressing tumor growth, and heat shock protein 70 (HSP70) in presenting tumor specific antigens. The objective of the present study was to investigate the relationship between lymph node metastasis and these two molecular biological markers in superficial esophageal carcinoma. Subjects were 37 patients with untreated submucosal esophageal carcinoma who underwent curative surgery. Among these patients, expression of CD68-positive macrophages in the tumor stroma and expression of HSP70 in tumor cells were analyzed. The results demonstrated that expression of CD68-positive macrophages was significantly greater among patients without lymph node metastasis (p<0.0001), and a significant correlation existed between HSP70 expression and CD68 expression (p=0.0125). In superficial esophageal carcinoma, lymph node metastasis is correlated with expression of CD68-positive macrophages in tumor stroma and expression of HSP70 in tumor cells. These two markers may therefore prove useful for therapy planning.

Prognostic significance of p27/kip1 and apoptosis in patients with colorectal carcinoma.

The protein p27/kip1 is a cyclin-dependent kinase inhibitor that regulates cell-cycle progression. In the present study, p27/kip1 expression as well as tumor cell proliferation and apoptosis were investigated in 80 colorectal carcinomas, using anti-p27/kip1 antibodies, in situ apoptosis detection kits and anti-PCNA antibodies. Immunohistochemical staining indicated that p27/kip1 was localized heterogeneously in the nuclei of cancer cells. The frequency of samples positive for p27/kip1 was 53.8% (43/80). There was no significant correlation between p27/kip1 status and clinicopathologic factors. Mean apoptotic index (AI) in p27/kip1-positive patients (3.22+/-1.65) was significantly higher than in p27/kip1-negative patients (2.46+/-1.44; p=0.033). No correlation was observed between p27/kip1 expression and the PCNA labeling index (PCNA-LI) (p=0.47). Overall survival was significantly longer for patients who were p27/kip1-positive (80.7%) compared to those who were negative (49.3%; p=0.0003). Univariate analysis revealed no significant differences between prognosis and AI or PCNA-LI. In multivariate analysis, p27/kip1 expression was found to be an independent prognostic marker (p=0.015). In conclusion, the present study shows that p27/kip1 is a potentially important prognostic and predictive marker for outcome in colorectal carcinoma. These results might be explained by the role of p27/kip1 in promoting apoptosis.

Analysis of mucosal regeneration and the expression profile of heat shock protein 70 in the isolated small bowel segment.

To investigate the mechanisms underlying the regeneration of the denervated small bowel segment from ischemic injury, we examined the heat shock protein 70 (HSP70) expression profile and compared it to the histopathological and proliferative changes seen in an isolated bowel segment using a rabbit model. Two weeks following the small bowel segment transplantation to the subcutaneous space, the vascular pedicle was sectioned. Next, the rabbits were divided into three groups based on the collection time of the isolated bowel segment (3, 7, and 14 days for Groups A, B, and C, respectively). The unsectioned small bowel segment was utilized as a control for each group. Histological studies showed that no experimental group recovered from mucosal injury. The bromodeoxyuridine labeling index showed that the more severe mucosal injury group had the highest bromodeoxyuridine incorporation. In the experimental groups, HSP70 immunoreactivity was intensely seen in the regenerating epithelial cells and inflammatory cells. In the control mucosa, HSP70 immunoreactivity was weakly seen in the subepithelial stromal tissue, crypt cells and not in epithelial cells. The present study shows that the isolated bowel segment requires longer periods for regeneration from ischemic injury and HSP70 may play an important role during the regeneration process.