Small bowel volvulus with chylous ascites: a case report.

Here, we report a rare case of small bowel volvulus with chylous ascites. A 93-year-old man with a medical history of angina pectoris presented to the emergency department with abdominal pain. Computed tomography revealed a whirl sign of the mesenteric vessels with the axis of the superior mesenteric artery. A diagnosis of small bowel volvulus was made, and emergency surgery was performed. Laparoscopic examination revealed chylous ascites. Due to severe intestinal edema and difficulty in manipulating the forceps, surgery was transferred to a laparotomy. The entire small bowel was twisted 360° counterclockwise, requiring manual untwisting. Examination of the intestinal tract after untwisting revealed no evidence of ischemia or necrosis. However, because a diverticulum was observed on the mesenteric side of the upper jejunum and considering the influence of secondary small bowel volvulus, partial small bowel resection was performed. The patient had a favorable postoperative course.

Serosal and muscular layers incision technique in laparoscopic surgery for gastric gastrointestinal stromal tumors.

INTRODUCTION: To minimize the resection of stomach tissue, especially for lesions close to the esophagogastric junction or pyloric ring, we developed laparoscopic wedge resection with the serosal and muscular layers incision technique (SAMIT) for gastric gastrointestinal stromal tumors. MATERIALS AND SURGICAL TECHNIQUE: SAMIT involves resection of the mucosal and submucosal layers and then an incision in serosal and muscular layers around the tumor. SAMIT is simple and does not require special devices. The data of 13 patients who underwent laparoscopic wedge resection with SAMIT for primary gastric gastrointestinal stromal tumors were reviewed. No intraoperative complications were observed, and postoperative stenosis occurred in only one case of a middle stomach lesion. Adequate oncological resection was performed in all cases. DISCUSSION: Laparoscopic wedge resection with SAMIT is technically and oncologically safe. It is useful for treating gastric gastrointestinal stromal tumors, including those close to the esophagogastric junction or pyloric ring.

Feasibility and functional efficacy of distal gastrectomy with jejunal interposition for gastric cancer: a case series.

INTRODUCTION: Distal gastrectomy with jejunal interposition (DGJI) has been used in our institution for selected patients with gastric cancer as a function-preserving gastrectomy. The aim of this retrospective study was to clarify the feasibility and functional efficacy of DGJI. METHODS: A retrospective analysis was performed in 61 patients who underwent DGJI between 2002 and 2011. RESULTS: Mean operation time was 393.8 min and blood loss was 463.3 ml. Postoperative early major complications developed in 2 (3.3%) patients. The most common complication was gastric stasis, occurring in 7 (11.5%) patients. All patients with complications recovered with conservative treatment, and no operative mortality occurred. Endoscopy 1 year after operation revealed reflux gastritis in 1 patient. Reflux esophagitis was not found in any patient. However, anastomotic ulcer was found in 12 (22.2%) patients over the 1-year period after operation. No patient reported symptoms of early and late dumping syndrome, and 1 (1.9%) patient self-reported diarrhea. CONCLUSIONS: DGJI was a feasible and safe procedure with several advantages in terms of less incidence of reflux gastritis and esophagitis, dumping syndrome and diarrhea. However, this procedure is complicated and time-consuming, and it is necessary to be aware of the potential occurrence of an anastomotic ulcer at the site of the gastrojejunostomy after DGJI.

Safety and effectiveness of mechanical versus hand suturing of intestinal anastomoses in an animal model of peritonitis.

Mechanical stapling for colorectal anastomosis is popular, but the safety of its use for anastomosis in peritonitis is unclear. We evaluated the safety and effectiveness of mechanically stapled vs. hand-sutured anastomosis by comparing wound healing in an animal model of bacterial peritonitis. Male Sprague-Dawley (n=48) rats underwent cecal ligation and puncture. After 24 h, rats were divided into two groups: the stapler group (cecal resection with mechanical stapler, n=24) and the hand-sutured group (cecal resection and stump closure with surgical absorbable suture, n=24). Anastomotic segments were excised and as indicators of wound healing, anastomotic bursting pressure (ABP) and tissue hydroxyproline concentration were determined over time. After harvesting, anastomotic segments were analyzed by quantitative real-time polymerase chain reaction (PCR) to determine relative expression of transforming growth factor-ß(1) (TGF-ß(1)) and vascular endothelial growth factor (VEGF) normalized to that of a constitutive gene. The operative time was significantly shorter in the stapler vs. the hand-sutured group. Both groups showed progressive increases in ABP over the postoperative period. ABP was significantly higher in the stapler vs. the hand-sutured group on postoperative days (PODs) 0 and 3. Tissue hydroxyproline concentration increased from POD 7 in both groups, but between-group difference was not significant. Both groups showed progressive increases in TGF-ß(1) and VEGF expression during the 7-day postoperative period. On POD 5, TGF-ß(1) gene expression was higher in the stapler vs. the hand-sutured group. VEGF gene expression was identical in both groups. In conclusion, anastomosis by stapler is safer and more effective than that by hand suturing in bacterial peritonitis, since it requires less operating time and creates stronger anastomoses in the early postoperative period.

Sodium alginate as an ideal submucosal injection material for endoscopic submucosal resection: preliminary experimental and clinical study.

BACKGROUND: Sodium alginate is used clinically in the treatment of peptic ulcer disease. Because of its viscosity, sodium alginate could possibly become a new submucosal injection material for use in endoscopic resection. OBJECTIVE: We evaluated the feasibility of endoscopic submucosal dissection (ESD) using sodium alginate. SETTING AND INTERVENTIONS: The lesion-lifting properties of sodium alginate were examined in porcine stomachs and were compared with those of normal saline solution and sodium hyaluronate solution. After confirming the proper concentration of sodium alginate, ESD using sodium alginate was performed in 11 patients with gastric mucosal cancer or adenoma. MAIN OUTCOME MEASUREMENT: The lesion-lifting properties of sodium alginate and clinical outcomes were assessed. RESULTS: The thickness of the submucosal elevation created by 3% sodium alginate in porcine stomach was equivalent to that of sodium hyaluronate. ESD using sodium alginate was completed successfully in all patients without adverse effects except in 1 patient in whom transient shrinkage of the gastric wall disappeared spontaneously after approximately 30 minutes. The mean tumor size was 15.3 mm. En bloc resection and a negative resection margin were obtained in all. Histopathologic examination revealed that all tumors were confined to the mucosal layer except for 1 that was confined to the submucosal layer without lymphovascular invasion, and there were no adverse effects such as tissue damage. No patient required additional treatment, and none showed recurrence during a median follow-up period of 28 months. LIMITATIONS: Small sample size. CONCLUSION: This preliminary study suggests that sodium alginate might be a novel, safe submucosal injection material for use in endoscopic resection. Further investigation of the properties of sodium alginate is warranted.

Activation of nuclear factor kappa B and induction of migration inhibitory factor in tumors by surgical stress of laparotomy versus carbon dioxide pneumoperitoneum: an animal experiment.

BACKGROUND: Surgical trauma may be associated with enhanced tumor growth and establishment. The authors studied the effect of carbon dioxide (CO(2)) pneumoperitoneum versus laparotomy on tumor necrosis factor-alpha (TNFalpha), migration inhibitory factor (MIF) expression, and nuclear factor kappa B (NFkappaB) activity in human gastric cancer. METHODS: Nude mice were inoculated intraperitoneally with human gastric cancer cells (MKN45). Then laparotomy, CO(2) pneumoperitoneum, and anesthesia alone were performed randomly. Tumor growth and associated TNFalpha and MIF expression and NFkappaB activity were determined. RESULTS: Total tumor weight, especially at the anterior abdominal wall, was higher after laparotomy than after CO(2) pneumoperitoneum (p < 0.05). The mRNA expression of TNFalpha was higher 24 and 48 h after laparotomy than after CO(2) pneumoperitoneum (p < 0.05 and p < 0.01, respectively). At all the examined time points, MIF mRNA expression also was higher after laparotomy than after CO(2) pneumoperitoneum (p < 0.05 until 1 week or p < 0.01 at 2 weeks). The NFkappaB protein was more activated after laparotomy than after CO(2) pneumoperitoneum 6 h subsequent to surgical procedures. CONCLUSION: After CO(2) pneumoperitoneum, tumors have less TNFalpha and MIF expression and less NFkappaB activity than after laparotomy. This may be associated with less tumor growth, supporting minimal invasive techniques in gastrointestinal oncologic surgery.

Increased mRNA expression of epidermal growth factor receptor, human epidermal receptor, and survivin in human gastric cancer after the surgical stress of laparotomy versus carbon dioxide pneumoperitoneum in a murine model.

BACKGROUND: Surgical impact may be associated with enhanced tumor growth and chemoresistance. This study aimed to evaluate the effect of surgical impact on the mRNA expression of survivin, epidermal growth factor receptor (EGFR), and human epidermal receptor (HER2) in tumors after pneumoperitoneum versus laparotomy. METHODS: Nude mice were inoculated intraperitoneally with human gastric cancer cells (MKN45). Then laparotomy, carbon dioxide (CO(2)) pneumoperitoneum, and anesthesia alone were performed randomly, after which EGFR, HER2, and survivin mRNA expression using reverse transcription-polymerase chain reaction (RT-PCR) was evaluated. RESULTS: The expression of EGFR and HER2 mRNA increased significantly after the experiment. However, it was higher after laparotomy than after CO(2) pneumoperitoneum at almost all examined time points. Survivin mRNA expression increased significantly in the first 48 h, then returned to the control level. It was higher after laparotomy than after CO(2) pneumoperitoneum 48 h after the surgical procedures. CONCLUSION: The expression of EGFR, HER2, and survivin increased after each surgical procedure. However it was lower after CO(2) pneumoperitoneum than after laparotomy. This might be associated with changes in the chemosensitivity of the remnant cancer cells after surgery, supporting the use of minimally invasive surgery for cancer.

Laparoscopic examination and resection for giant lipoma of the omentum: a case report and review of related literature.

We report herein the case of a giant lipoma of the greater omentum that was treated by laparoscopic surgery. A 71-year-old male patient was admitted with a diagnosis of sigmoid colon cancer. During preoperative examination, a gallbladder stone and an intra-abdominal giant lipoma were accidentally diagnosed. Laparoscopic examination revealed a smooth-surfaced, giant yellow tumor at the lower border of the greater omentum that was unattached to the surrounding organs. After laparoscopic resection of the tumor and cholecystectomy, a 10-cm midline incision was made in the lower abdomen to remove the tumor and the gallbladder. We then performed a sigmoidectomy for sigmoid colon cancer through the same laparotomy. The resected tumor measured 29 x 19 x 3 cm and weighed 1250 g, and a histopathologic examination revealed a benign lipoma. Laparoscopic examination and resection of a giant lipoma of the omentum are particularly useful.

Effect of bevacizumab, a humanized monoclonal antibody to vascular endothelial growth factor, on peritoneal metastasis of MNK-45P human gastric cancer in mice.

BACKGROUND: The aim of this study was to clarify the effect of bevacizumab on gastric cancer with peritoneal metastasis in nude mice. MATERIALS AND METHODS: The expression of vascular endothelial growth factor mRNA (VEGF mRNA) in four gastric cancer cell lines, NCI-N87, MKN-45, MKN-45P, and Kato-III, was examined by polymerase chain reaction. We created a model of peritoneal metastasis by injecting mice with the human gastric cancer cell line MKN-45P. Mice were injected intraperitoneally with bevacizumab (0.1 mg/100 microL) on days 5-14, after inoculation (n = 10) or with phosphate-buffered saline (PBS) over the same time period (n = 10). The maximum abdominal circumference, ascites volume, and the total number and weight of peritoneal tumors were measured. To assess the effect of bevacizumab on angiogenesis, immunohistochemical analysis was performed. RESULTS: VEGF mRNA was expressed at a high level in MKN-45P cells as well as MKN-45 and Kato-III. The mean maximum abdominal circumference and ascites volume in the bevacizumab group were significantly less than those in the control group (P < 0.001, respectively). The total weight of disseminated tumors in the bevacizumab group was also significantly less than that in the control group (P < 0.01). In addition, immunohistochemical analysis of CD31-stained peritoneally disseminated nodules showed that the vessel area in the bevacizumab group was significantly less than that in the control group (P < 0.001). CONCLUSIONS: These results show that intraperitoneal administration of bevacizumab inhibits peritoneal metastasis and reduces malignant ascites in tumor-bearing mice.

Computed tomography of the gastrointestinal manifestation of hereditary angioedema.

We report a case of gastrointestinal manifestation of hereditary angioedema. Computed tomography (CT) revealed wall thickening of the gastric antrum, duodenum, and jejunum. Dilatation of the third part of the duodenum, thickening of the small bowel mesentery and omentum, and retroperitoneal edema were present. The importance of considering this condition in patients presenting such CT findings correlated with the appropriate history is discussed.

Transient liver dysfunction after laparoscopic gastrectomy for gastric cancer patients.

INTRODUCTION: The effect of laparoscopic surgery under CO2 pneumoperitoneum on liver function is not clear. The aim of this study was to clarify whether laparoscopy-assisted distal gastrectomy (LADG) is associated with changes in liver function compared with open distal gastrectomy (ODG). METHODS: A total of 205 patients who underwent LADG (n = 147) or ODG (n = 58) between January 1994 and April 2004 were included in this study. Liver function tests-aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin, total bilirubin-were examined before surgery and at 1, 3, and 7 days after surgery. The postoperative clinical course was compared between the two groups. RESULTS: AST levels on day 1 and ALT levels on days 1 and 3 were significantly higher in the LADG group. Albumin levels showed a marked decrease after operation in both groups, but the level recovered more rapidly in the LADG group than in the ODG group, showing significant differences on days 3 and 7. The total bilirubin levels remained unchanged from baseline. The postoperative complication rate was similar in the two groups, although 3 LADG patients among the 27 patients with liver disease suffered severe enteritis. CONCLUSIONS: Transient liver dysfunction was documented in patients after laparoscopic gastrectomy under CO2 pneumoperitoneum.