A case of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) with multiple polyps arising in the cecum and appendix.

We present the case of a 32-year-old female with cecal and appendiceal polyps that were removed by laparoscopy-assisted surgery. She also had recurrent nosebleeds due to telangiectases in the nasal mucosa and arteriovenous malformations in the lung, all of which contributed to the diagnosis of hereditary hemorrhagic telangiectasia.

Long-term results of endovascular treatment for splenic artery aneurysms.

AIM: The aim of this paper was to evaluate our single-center experience of the management of splenic artery aneurysm (SAA), with particular attention to the long-term results of endovascular treatment. METHODS: Thirty-eight patients with the diagnosis of SAA at the Tokyo University Hospital during the past 23 years were retrospectively reviewed. Interventions were considered for patients with SAA>2 cm in diameter. Nine patients were treated by transcatheter embolization (TE), and 8 by open surgical repair (SR). Twenty-one patients were observed (OB). TE was performed with microcoils placed distal and proximal to the aneurysm in the afferent artery to isolate the aneurysm. RESULTS: In the TE group, the primary technical success rate was 100%. No 30-day mortality or any catheter-related complication was observed. The median length of hospital stay after TE, excluding one patient who required further surgery, was shorter than that after SR (8 versus 16 days, P=0.001). During follow-up (median =45 months), no patient died and no recurrence of SAA was observed. In the SR group, all aneurysms were repaired successfully without any severe complication, and no aneurysm-related death occurred during follow-up (median =57 months). In the OB group, no aneurysm rupture or increase in aneurysm size was observed during follow-up (median =35 months). CONCLUSION: TE provided good early and long-term results, comparable to those obtained with conventional SR. In addition, TE had several advantages associated with its minimal invasiveness. TE by the isolation technique could be the first-line strategy for all SAA requiring treatment.

Phase II study of weekly intravenous and intraperitoneal paclitaxel combined with S-1 for advanced gastric cancer with peritoneal metastasis.

BACKGROUND: A phase II study to evaluate the efficacy and tolerability of weekly i.v. and i.p. paclitaxel (PTX) combined with S-1 was carried out in gastric cancer patients with peritoneal metastasis. PATIENTS AND METHODS: Gastric cancer patients with peritoneal dissemination and/or cancer cells on peritoneal cytology were enrolled. PTX was administered i.v. at 50 mg/m(2) and i.p. at 20 mg/m(2) on days 1 and 8. S-1 was administered at 80 mg/m(2)/day for 14 consecutive days, followed by 7 days rest. The primary end point was the 1-year overall survival (OS) rate. Secondary end points were the response rate, efficacy against malignant ascites and safety. RESULTS: Forty patients were enrolled, including 21 with primary tumors with peritoneal dissemination, 13 with peritoneal recurrence and six with positive peritoneal cytology only. The median number of courses was 7 (range 1-23). The 1-year OS rate was 78% (95% confidence interval 65% to 90%). The overall response rate was 56% in 18 patients with target lesions. Malignant ascites disappeared or decreased in 13 of 21 (62%) patients. The frequent grade 3/4 toxic effects included neutropenia (38%), leukopenia (18%) and anemia (10%). CONCLUSION: Combination chemotherapy of i.v. and i.p. PTX with S-1 is well tolerated and active in gastric cancer patients with peritoneal metastasis.

Preoperative evaluation of enterovesical fistula using magnetic resonance imaging: case report.

We report a case of sigmoido-vesical fistula due to sigmoid diverticulitis. Magnetic resonance imaging enabled us to visualize the fistula itself in the bladder wall. Magnetic resonance imaging was highly effective in making a precise diagnosis and also provided important additional information for the preoperative work-up of the patient.

Selective and sustained delivery of basic fibroblast growth factor (bFGF) for treatment of peripheral arterial disease: results of a phase I trial.

OBJECTIVES: The aim of this study was to evaluate the safety of selective and sustained delivery of basic fibroblast growth factor (bFGF) using acidic gelatine hydrogel microspheres (AGHMs) for the treatment of peripheral arterial disease (PAD). MATERIALS AND METHODS: We conducted a non-randomised and uncontrolled trial involving prospective observation of eight patients (eight limbs) with PAD - five limbs with arteriosclerosis obliterans and three limbs with thromboangiitis obliterans, five limbs (three arms and two legs) with critical limb ischaemia (CLI) and three limbs with intermittent claudication (IC) - who were followed up for 6 months or more. AGHM suspension containing 100 microg bFGF was infused into the artery of the affected limb. Besides evaluation of safety and changes in symptoms, resting ankle-brachial pressure index measurement and transcutaneous PO(2) (tcPO(2)), angiography were conducted at baseline and then at various time points. Skin perfusion pressure as an index of CLI and claudication distance as an index of IC were also used to assess clinical improvement and limb perfusion. RESULTS: No serious adverse events were observed. All cases showed improvement in symptoms, although this was temporary in some patients. CONCLUSION: Selective delivery of bFGF using AGHMs was suggested to be safe and well-tolerated in patients with PAD.

Angleplasty in gastric tube reconstruction after esophagectomy.

Anastomotic leakage after radical esophagectomy is mostly caused by the hypoxia and high tension at the esophagogastric anastomotic site. Here, we introduce a new surgical technique, 'Angleplasty,' to enable the tensionless anastomosis at a highly oxygenic site of gastric conduit. In short, the seromuscular layer is cut for a perpendicular direction against a lesser curvature at a gastric angle and the gastric wall is carefully divided between the muscular and submucosal layers for longitudinal direction for 4-5 cm in length. Then, the wound is closed with seromuscular sutures for longitudinal direction. With this maneuver, the lesser curvature of the gastric roll is significantly elongated and the anastomosis site of the gastric conduit can be moved more distal on the greater curvature of the stomach where it is expected to receive more oxygen supply. This technique takes only several minutes, but provides highly favorable conditions for esophagogastric anastomosis and thus is clinically useful to reduce the risk of anastomotic leakage after esophagectomy.

Chronic expanding hematoma in combination with a pseudoaneurysm: a case report.

After bleeding from trauma or surgery, most of the hematomas undergo spontaneous reabsorption. But, in some rare cases, hematomas persist for long periods as slowly expanding masses for months or years. These hematomas were termed as chronic expanding hematomas. In this report, we describe a case of chronic expanding hematoma with a pseudoaneurysm that underwent surgical biopsy, which led to an increase in its expansion speed.

Unusual pressure-induced rupture of colonic volvulus in a patient with long-term corticosteroid therapy.

Perforation due to colonic volvulus is typically considered to occur following ischemic necrosis of the intestinal wall. In this report, we report a rare case of sigmoid colon volvulus rupture caused by increasing intraluminal pressure without any sign of ischemia. The patient was an 88-year old Japanese male, who had been treated with 5 mg of oral prednisolone daily for 8 years. He consulted for severe abdominal pain that had lasted for three days. X-ray and computed tomography showed free peritoneal air, suggesting peritonitis. He was diagnosed with sigmoid colon volvulus perforation and underwent emergency surgery. Pathological examination showed no ischemic necrosis around the perforations in the resected intestine. As a result, we came to believe that the fragility of the colonic wall, caused by the patient's long-term use of corticosteroid, had lowered the threshold for pressure-induced colonic rupture.

Good correlation between cerebral oxygenation measured using near infrared spectroscopy and stump pressure during carotid clamping.

AIM: Intraoperative hypoperfusion ischemia is one factor that leads to perioperative stroke during carotid endarterectomy. Selective shunting is one way to reduce intraoperative hypoperfusion, but to shunt selectively needs a sensitive and simple monitoring system together with the rules for insertion. Near infrared spectroscopy (NIRS) is a monitoring system that can be used throughout the operation, and reflects the cerebral oxygenation instantly, but its value in insertion of shunt tubes is still controversial. The aim of this study was to determine criteria that can be used to insert shunt tubes. METHODS: Forty-three consecutive patients with severe carotid stenosis undergoing carotid artery surgery with NIRS monitoring were enrolled in the study. Under general anesthesia, the optodes of NIRS were placed bilaterally on the forehead. Throughout the operation, regional saturation of the frontal lobe (SdO2) was monitored every 5 s. RESULTS: All operations were performed without any perioperative deaths. NIRS showed that SdO2 fell rapidly as soon as the artery was cross-clamped, and reached the lowest level after 60 s. SdO2 change at 60 s and the stump pressure showed good correlation (r=0.65), and stump pressure of 40 mmHg was almost equivalent to 5% SdO2 decrease in NIRS. CONCLUSION: NIRS monitoring is suitable for monitoring during carotid endarterectomy for selective shunting, because it can be used throughout the operation and shows the immediate change in oxygenation. There is a possibility that a decrease of 5% can be used as a decisive value for shunt insertion.

Biocompatible micellar nanovectors achieve efficient gene transfer to vascular lesions without cytotoxicity and thrombus formation.

Gene therapy, a promising treatment for vascular disease, requires appropriate gene vectors with high gene transfer efficiency, good biocompatibility and low cytotoxicity. To satisfy these requirements from the approach of nonviral vectors, a novel block copolymer, poly(ethylene glycol) (PEG)-block-polycation, carrying ethylenediamine units in the side chain (PEG-b-P[Asp(DET)]) was prepared. PEG-b-P[Asp(DET)] formed a polyplex micelle through polyion complex formation with plasmid DNA (pDNA). The PEG-b-P[Asp(DET)] polyplex micelle showed efficient gene expression with low cytotoxicity against vascular smooth muscle cells in vitro. It also showed reduced interactions with blood components, offering its feasibility of gene delivery via the vessel lumen. To evaluate in vivo gene transfer efficiency for vascular lesions, PEG-b-P[Asp(DET)] micelle was instilled into rabbit carotid artery with neointima by an intravascular method, and expression of the reporter gene in vascular lesions was assessed. Polyplexes from homopolymer P[Asp(DET)] and branched polyethyleneimine (BPEI) were used as controls. Ultimately, only the polyplex micelle showed appreciable gene transfer into vascular lesions without any vessel occlusion by thrombus, which was in strong contrast to BPEI and P[Asp(DET)] polyplexes which frequently showed occlusion with thrombus. These findings suggest that the PEG-b-P[Asp(DET)] polyplex micelle may have promising potential as a nonviral vector for the treatment of vascular diseases.

A study of dendritic and endothelial cell interactions in colon cancer in a cell line and small mammal model.

AIM: Historically, cancer therapy directly targeting tumor cells have yielded suboptimal clinical results, and therefore anti-angiogenic therapy that targets tumor cells indirectly through impairing tumor vasculature is now considered to be one of the novel approaches potentially effective against various types of cancer. In this study, we evaluated whether lysates of endothelium could be effectively pulsed in dendritic cells (DCs), to enhance their anti-tumor effects. METHODS: For this purpose, we prepared DCs of BALB/c mouse, incubated them with lysates of autologous or xenogeneic endothelium, and tested their anti-tumor effects in two syngeneic models of colon cancer. RESULTS: DCs pulsed with the respective endothelium lysates significantly inhibited the growth of subcutaneous tumors as well as pulmonary metastases in mice, and their anti-tumor effect was superior to that of unpulsed DCs. Immunohistopathological analysis showed significant decrease in the mean vascular density of tumors, correlating well with the extent of tumor inhibition. In vitro analysis of splenocytes isolated from immunized mice revealed an induction of cytotoxic T lymphocytes and activation of natural killer cells, with a lytic activity against activated endothelium but not tumor cells. In addition, antibodies reacting with activated endothelium, but not tumor cells, were detected in murine sera by ELISA, and their function was confirmed by complement-dependent cytotoxicity assay. CONCLUSIONS: Our present results suggest that lysates of endothelium can be effectively pulsed in DCs and enhance their anti-tumor effects through induction of anti-angiogenesis, and therefore should have important clinical implications for adjuvant cancer therapy.

Objective assessment of nerve injury after greater saphenous vein stripping.

AIM: The complication of nerve injury after greater saphenous vein stripping for varicosity is subjective, and a method for objective evaluation has never been established. The aim of this study was to evaluate postoperative sensory changes by quantitative assessment of current perception threshold (CPT), and to clarify the relation between CPT and symptoms. PATIENTS AND METHODS: Between January 2003 and August 2005, 27 limbs in 18 patients were enrolled. Quantitative sensory function was determined through CPT using a Neurometer (Neurotron, Inc., USA), with which saphenous nerve neural fiber selective minimum sensing values against three electrical stimuli (2000, 250, 5 Hz) were measured. CPT measurements were scheduled on the day before the operation, and 2-7 days, 1, 3, and 6 months after the operation. RESULTS: An increase in CPT value of more than 20% or decrease to below 50% compared to the preoperative value with at least two stimuli was defined as CPT abnormality. Subjective symptoms were observed in 13 limbs in the early postoperative period, and 10 limbs showed CPT abnormality. In 6 limbs with a CPT increase over 20% with all three stimuli, neurological symptoms continued for 6 months. CONCLUSIONS: CPT evaluation provides an objective indication of neurological symptoms in the lower limb following varicose vein surgery.

The high prevalence of colorectal neoplasms in preoperative patients with abdominal aortic aneurysm or peripheral artery disease.

OBJECTIVE: In Japan, the incidence of both colorectal carcinoma and vascular disease is increasing. We screened preoperative patients with abdominal aortic aneurysm (AAA) or peripheral artery disease (PAD) for colorectal cancer. DESIGN OF STUDY: This study was retrospective and cross-sectional. MATERIALS: The subjects were 492 patients admitted for elective surgery of AAA or PAD. METHODS: The patients underwent immunochemical faecal occult blood tests (FOBT) before operation, and those with positive results underwent investigations for colorectal neoplasm. We compared the results with that of screening programmes performed on the general population. RESULTS: Of the 408 patients that underwent FOBT, 104 (25.5%) were positive. After colonoscopy, six (1.5%) had colorectal carcinoma and 16 (3.9%) had advanced adenoma. These values were several folds higher than that for the general population in Japan. CONCLUSIONS: Patients with AAA or PAD carry a high risk for colorectal neoplasm.

Plantar flexion as an alternative to treadmill exercise for evaluating patients with intermittent claudication.

OBJECTIVE: The aim of this study was to examine whether the plantar flexion test could adequately replace treadmill testing in patients who were unable to exercise. DESIGN: Prospective observational study. PATIENTS: Twenty-seven patients with intermittent claudication secondary to peripheral arterial disease (PAD). METHODS: Patients performed two treadmill tests and two plantar flexion tests. Ankle pressure, near infrared spectroscopy (NIRS) data, heart rate and blood pressures were monitored along with pain-free and maximum walking distances for treadmill, pain-free and maximum exercise time for plantar flexion. RESULTS: Maximum exercise time and walking distance were well correlated (R=0.74). Eleven patients (41%) developed non-claudicating symptoms during the treadmill test but not during the flexion test. Rate pressure product was significantly higher after the treadmill but not after the plantar flexion. CONCLUSIONS: Plantar flexion test showed good reliability and correlation. Plantar flexion may serve as an alternative to treadmill testing in evaluating muscle pain in patients with intermittent claudication.

Reduced vascular reserve measured by stressed single photon emission computed tomography carries a high risk for stroke in patients with carotid stenosis.

AIM: A few studies have observed reduced vascular reserve measured by single photon emission computed tomography (SPECT) to be a risk factor for stroke in patients with carotid artery occlusion, but stenosis has been excluded from these former studies. This study has evaluated the prognosis of reduced vascular reserve in patients with stenosis, and the effect of carotid endarterectomy (CEA) on these patients. METHODS: Forty patients diagnosed as having >70% stenosis of the carotid artery at the University of Tokyo Hospital, between 2001 and 2004, underwent acetazolamide-stress SPECT test first. A resting SPECT study was performed on a different day from the stressed SPECT study. The patients were grouped as having reduced vascular reserve or normal vascular reserve from the SPECT results. Analysis of risk factors and the stroke-free curve analysis for reduced vascular reserve was performed. RESULTS: Of the 40 patients, 24 (60%) had reduced vascular reserve and 18 underwent CEA. The mean follow-up period was 21.5+/-15.5 months (mean+/-SD). Four strokes occurred during follow-up: in 1 patient with CEA and 3 without CEA. All stroke patients had reduced vascular reserve. The patients with reduced vascular reserve without any surgery had a significantly lower stroke-free rate compared with those with normal vascular reserve or reduced vascular reserve, but also receiving CEA. CONCLUSIONS: We propose performing SPECT tests in patients with severe carotid stenosis regardless of symptoms, and performing CEA on those with a reduction in vascular reserve.

Popliteal venous aneurysm with repeated episodes of pulmonary embolism. Case report and literature review.

Popliteal venous aneurysm (PVA) is a rare, but a life-threatening, disease causing pulmonary embolism (PE). We experienced a case of primary PVA with repeated PE attacks without intraluminal thrombus. Surgical repair was safely performed with a temporary vena cava filter and an intraoperative external pneumatic compression device to the calf. During the perioperative period, pneumatic compression was continued until the patient returned to a normal ambulatory status. The patient has had no episode of PE for 24 months since the operation.

Chromosome 18q deletion and Smad4 protein inactivation correlate with liver metastasis: A study matched for T- and N- classification.

Smad4 protein, whose gene is coded at chromosome 18q21.1, is an important tumour suppressor that mediates transforming growth factor-beta. It has been reported that inactivation of the Smad4 gene and allelic loss of chromosome 18q correlate with liver metastasis and poorer prognosis in colorectal cancers. Utilising a recently developed method of immunohistochemical staining for Smad4 protein, we focused on the specific impact of Smad4 protein expression on liver metastasis in colorectal cancer. We also evaluated the association between chromosome18q deletion and liver metastasis. We selected 20 colorectal cancers with liver metastasis for the experimental group, and 20 cases without liver metastasis for the control. In order to exclude the influence of lymph node metastasis, all cases were lymph node negative. In addition, the two groups were matched for tumour depth, tumour differentiation and tumour location. We compared the expression level of Smad4 protein immunohistochemically in these 20 matched pairs. We also compared the loss of heterozygosity status at chromosome 18q in these 20 matched pairs. Immunohistochemical staining revealed a significant difference (P = 0.024) in the level of Smad4 protein between the two groups. We also observed a significantly different (P=0.0054) ratio of allelic deletion at chromosome 18q21. Smad4 protein expression level and allelic loss at 18q21 are associated with the process of liver metastasis in colorectal cancers evaluated when excluding clinical and pathological features except for liver metastasis.