Laparoscopic repair of a primary parahiatal hernia combined with gastric volvulus: a case report and literature review.

BACKGROUND: Parahiatal hernias present a hernial orifice at the diaphragm that is adjacent to the esophageal hiatus, differing from the paraesophageal type of hiatal hernias. Although diagnostic imaging has advanced in recent years, diagnosing parahiatal hernias remains challenging. We herein report a case in which we performed laparoscopic surgery and intraoperatively diagnosed a parahiatal hernia. CASE PRESENTATION: A 67-year-old man presented to our hospital with difficulty eating, epigastric pain, and vomiting. We suspected a paraesophageal hiatal hernia. Laparoscopic surgery was performed, and a diagnosis of parahiatal hernia was made. We closed the hernial orifice with direct simple closure using nonabsorbable threads. The patient's postoperative recovery course was reasonable, and he was discharged on the twelfth postoperative day. CONCLUSIONS: Parahiatal hernias are rare, and a definitive diagnosis is difficult. Laparoscopic surgery can help accurately diagnose and treat patients presenting with the condition.

Incidental Gallbladder Cancer on Cholecystectomy: Strategy for Re-resection of Presumed Benign Diseases from a Retrospective Multicenter Study by the Yokohama Clinical Oncology Group.

BACKGROUND/AIM: Current expert consensus recommends re-resection for incidental gallbladder cancer (IGBC) of pT1b-3. This study examined whether this consensus was reasonably applicable to patients with IGBC in one Japanese region. PATIENTS AND METHODS: This was a multicenter, retrospective analysis of cholecystectomies for presumed benign diseases between January 2000 and December 2009. RESULTS: IGBC was diagnosed in 70 (1.0%) out of 6,775 patients undergoing cholecystectomy. Five-year disease-specific cumulative survival was 100% in 19 patients with pT1a, 80.0% in five with pT1b, 49.5% in 33 with pT2, and 23.1% in 13 with pT3. Re-resection was not performed for the 24 patients with pT1a/1b disease, whereas 24 out of 46 patients with pT2/3 underwent re-resection. Regardless of re-resection, independent factors associated with a poor prognosis on multivariate analysis were grade 2 or poorer disease and bile spillage at prior cholecystectomy. In the 24 patients with pT2/3 re-resection, 11 patients without either of these two factors had significantly better 5-year disease-specific cumulative survival than the 13 patients with one or two independent factors associated with a poor prognosis (72.7% vs. 30.8%, p=0.009). CONCLUSION: This Japanese regional study suggests that indication of re-resection for IGBC should not be determined by pT-factor alone and that much more attention should be paid to pathological and intraoperative findings at prior cholecystectomy.

High-Mobility Group Box 1 expression predicts survival of patients after resection of adenocarcinoma of the ampulla of Vater.

BACKGROUND: Expression of High-Mobility Group Box 1 (HMGB1), a multifunctional protein involved in DNA function as well as cell proliferation, inflammation, and the immune response, has been reported to be prognostic in several types of malignancies. However, the prognostic value of HMGB1 in ampullary cancer has not been studied. METHODS: Patients with adenocarcinoma of the ampulla of Vater who underwent R0 resection with pancreaticoduodenectomy between 2001 and 2011 were included in the present multi-institutional study. The degree of HMGB1 expression was examined in each resected specimen by immunohistochemical staining. RESULTS: A total of 101 patients were enrolled of which, 79 patients were eligible. High expression of HMGB1 was observed in 31 (39%) patients. Blood loss, transfusion, tumor stage, nodal status, and HMGB1 expression were identified as predictors with univariate analysis. Multivariate analysis showed that transfusion, lymph-node metastasis, and high HMGB1 expression were independent predictors of poor overall survival. Subgroup analysis showed that high HMGB1 expression was predictive, especially in patients who did not receive adjuvant chemotherapy. CONCLUSIONS: High HMGB1 expression is an independent predictor of poor prognosis in patients with adenocarcinoma of the ampulla of Vater not treated with adjuvant chemotherapy.

Predictive factors for bile leakage after hepatectomy for hepatic tumors: a retrospective multicenter study with 631 cases at Yokohama Clinical Oncology Group (YCOG).

BACKGROUND: International Study Group of Liver Surgery (ISGLS) proposed the standardized definition for bile leakage (BL) after hepatectomy (Hx) at 2011 to precisely perceive incidence and predictive factors of this critical condition. METHODS: We conducted a multicenter retrospective study using the ISGLS definition of BL after Hx. RESULTS: Perioperative data regarding 631 patients undergoing elective Hx for hepatic tumors without biliary reconstruction performed between January 2009 and December 2011 were analyzed. BL was observed in 30 patients (4.8%). (Grade A, 8 (1.3%); B, 21(3.3%); C, 1 (0.2%)). Five independent predictors (diagnosis of liver metastases, prolonged operation, high risk procedures defined as Hx with broad exposure of the hilar Glissonean sheath, low platelet count and high serum total bilirubin on postoperative day 1) for grade B/C BL were elucidated by the multivariate analysis. When the study cohorts were divided into groups by number of accompanying these predictors, the more the accompanying independent predictors, the higher the incidence of BL. Notably, incidence of BL exceeded 40% in patients with four or more of these predictors. CONCLUSIONS: Risk stratification for BL after Hx can be achievable using independent predictors clarified in this study. However, proper management for high risk patients remains to be elucidated.

Incidence and risk factors for rectovaginal fistula after low anterior resection for rectal cancer.

BACKGROUND: The rectovaginal fistula (RVF) is a rare complication after low anterior resection (LAR) for rectal cancer. The aim of this study was to evaluate the risk factors for RVF after LAR for rectal cancer. METHODS: This was a retrospective multi-institution study of 371 female rectal cancer patients who underwent LAR with anastomosis between January 2007 and December 2011. Patient-, tumor-, and surgery-related variables were examined by univariate and multivariate analyses. RESULTS: The overall RVF rate was 3.0 % (11/371). The RVF was diagnosed on median postoperative day 83 (15-766). In 81.8 % (9/11) of the patients, the diagnosis of RVF was made after hospital discharge. Multivariate analysis identified prognostic nutritional index (PNI; odds ratio (OR) 6.97; 95 % confidence interval (CI) 1.47-33.08; P = 0.015), preoperative chemotherapy (OR 27.31; CI 3.49-213.62; P = 0.002), tumor size (OR 5.90; CI 1.04-33.47; P = 0.045), intraoperative bleeding (OR 13.91; CI 1.34-144.42; P = 0.027), and lateral lymph node dissection (OR 4.92; CI 1.02-23.63; P = 0.045) as independent risk factors for RVF after LAR. CONCLUSIONS: Risk factors of RVF were PNI (<45), preoperative chemotherapy, tumor size (≧ 50 mm), intraoperative bleeding (≧ 200 ml), and lateral lymph node dissection. Before an operation, obtaining the information about these risk factors is of great importance in LAR for rectal cancer.

Macroscopic type is a prognostic factor for recurrence-free survival after resection of gastric GIST.

BACKGROUND: Accurate evaluation of the biological behavior of Gastrointestinal stromal tumor and careful selection of patients with a high risk for tumor recurrence are necessary. In the present study, we analyzed prognostic factors in patients with GIST. PATIENTS AND METHODS: A total of 214 patients who had undergone curative resection of a localized primary gastric GIST without adjuvant therapy were enrolled in this retrospective study. Prognostic factors were analyzed. The growth pattern was classified as intramural, endoluminal, exoluminal, or mixed- type. RESULTS: On univariate and multivariate analyses, recurrence was predicted by exoluminal or mixed-type (hazard ratio [HR]=3.7, p=0.043), tumor size of >3.5 cm (HR=7.1, p=0.01), and mitotic rate of >5/50 high-power fields (HR=7.9, p<0.001). CONCLUSION: It is suggested that exoluminal or mixed-type is independently associated with recurrence of surgically resected gastric GIST in addition to tumor size and mitotic rate.

Telomerase activity and Bcl-2 expression in gallbladders of pancreaticobiliary maljunction patients: a preliminary study.

BACKGROUND: The congenital anomaly pancreaticobiliary maljunction (PBM) is considered to be a precancerous disease. PBM carcinogenesis is believed to be an accumulation of gene abnormalities, but the early events causing PBM carcinogenesis are still unclear. In the present study, telomerase activity and Bcl-2 expression in the gallbladder mucosa of PBM and non-PBM gallbladders were investigated. METHODS: The operative gallbladder materials were from five control cases, two cases of non-PBM gallbladder cancer, three of PBM gallbladder cancer, and three of non-neoplastic PBMs. Multiple sampling was performed from each gallbladder. The studies performed were: (1) immunohistochemistry of p53, Ki-67, and Bcl-2; (2) survey of k-ras point mutations; and (3) measurement of telomerase activity in each sample. RESULTS: In the cases of non-PBM cancer, abnormalities from the above studies were detected only in the cancerous lesions. Normal-appearing mucosa did not show Bcl-2 expression or telomerase activity. However, in the cases of PBM cancer, normal-appearing mucosa showed telomerase activity and Bcl-2 expression, but did not show p53, Ki-67, or k-ras abnormalities. In the non-neoplastic PBM, all samples showed Bcl-2 expression, and many showed telomerase activity. CONCLUSIONS: Bcl-2 expression and activation of telomerase are probably early events causing carcinogenesis of the PBM gallbladder mucosa. They might be important factors causing carcinogenesis associated with chronic inflammation.

Basaloid cell carcinoma of the esophagus with a metastatic neck tumor of unknown origin: report of a case.

A 51-year-old man was admitted to our hospital with a tumor in the right anterior region of his neck. Aspiration biopsy revealed squamous cell carcinoma (SCC). Further investigations, including upper gastro-intestinal series and endoscopy, showed two flush lesions in the middle and lower thoracic esophagus. An endoscopic biopsy was done and the pathological findings indicated poorly differentiated SCC. He underwent esophagectomy with three-field lymph node dissection, including the neck tumor. Histological findings revealed that the tumor in the middle thoracic esophagus was moderately differentiated SCC, and that the other tumor below it was basaloid cell carcinoma (BCC). The depths of invasion were to the lamina propria mucosae for the former and to the submucosal layer for the latter. There was no lymphatic invasion, venous invasion, or lymph node metastasis. A diagnosis of poorly differentiated SCC of unknown origin was made for the neck tumor. Postoperative recombinant chemotherapy with cisplatin and 5-fluorouracil was given for the unknown primary site, which we still have not identified. No recurrence of the esophageal cancer has been detected.

Changes in the response of neutrophils to endotoxin priming following major abdominal surgery.

Endotoxin (ETX) primes polymorphonuclear cells (PMNs) for the subsequent release of reactive oxygen species (ROS) in response to various stimulants such as phorbol myristate acetate (PMA). Although PMNs contribute to oxidative stress after stimulation by standard stimulants and after priming by many humoral factors, it is unknown whether the PMNs from patients at different postoperative times exhibit the same response to the same standard stimulant. We examined the response of PMA-induced production of ROS from PMNs at various intervals after major abdominal surgery in response to ETX priming. This study was a prospective clinical and laboratory study conducted over a 7-day period that involved 25 patients who were referred for elective major abdominal surgery (8 for gastric cancer, 9 for colonic cancer, 8 for rectal cancer). Blood was sampled on the day before operation and on postoperative days (PODs) 1, 3, and 7. For each sample we measured luminol-dependent chemiluminescence (CL), the time to peak counts (Tmax) of PMNs stimulated by PMA, and the serum ETX level. We studied the correlation between CL and ETX in samples from PODs 1 and 3. We also studied the CL of PMNs on PODs 1 and 3 preincubated (primed) with various concentrations of ETX (0, 20, 40, 60, and 100 pg/ml). We found that CL decreased on POD 1 compared with the preoperative level (p <0.05) because of the decreased Tmax. The level of CL per 1 ml of whole blood, however, was higher on PODs 1 and 3 than preoperatively. During this time, leukocytosis should compensate for the impaired production of ROS by an individual PMN. The serum ETX level was increased on POD 1 (p <0.05). There was a negative correlation between CL and ETX on POD 1 (correlation coefficient ?0.62, p < 0.01) and a positive correlation on POD 3 (0.61, p <0.01). CL on POD 3 was accelerated by ETX priming, but the CL on POD 1 was depressed by the priming using a low concentration of ETX. The mode of the response of PMNs to ETX priming differed between PODs 1 and 3. On POD 1 the responses of PMNs to environmental stimulants is suppressed, but by POD 3 these responses had increased.