Robotic surgery for simultaneous gastric and rectal cancers.

The number of patients with multiple primary malignancies is increasing due to the improvements in diagnostic techniques, which increases the necessity of simultaneous resection. Meanwhile, minimally invasive robotic surgery is becoming popular in Japan, and its use in multiple cancer resection will increase. We present our experience with the settings and ports placement when using the da Vinci Xi system for simultaneous resection of rectal and gastric cancer.

FDG-PET for preoperative evaluation of tumor invasion in ampullary cancer: A retrospective analysis.

BACKGROUND: Tumor invasion is the most significant prognostic factor in ampullary cancer and is thus a crucial factor in decision making for treatment. Endoscopic ultrasound can be performed to evaluate tumor invasion, but its diagnostic accuracy varies depending on the endoscopist. This study aimed to assess the usefulness of fluorodeoxyglucose positron emission tomography (FDG-PET) for preoperatively predicting tumor invasion in ampullary cancer. METHODS: We retrospectively evaluated 44 patients with ampullary cancer (adenoma, n = 6; adenocarcinoma, n = 38) who underwent surgical resection. The SUVmax of the ampullary tumor site was assessed using FDG-PET, and the correlation among tumor invasion, lymph node metastasis, and other clinicopathological factors was evaluated. RESULTS: The SUVmax of the ampullary tumor site gradually increased depending on the extent of tumor invasion (p = 0.0075). Moreover, the SUVmax was significantly different between ≤T1a and ≥T1b, which is an indication for endoscopic papillectomy or surgical resection (p = 0.0015). The SUVmax of the ampullary section was significantly correlated with lymph node metastasis (p = 0.035). CONCLUSION: The SUVmax of the ampullary tumor site is correlated with tumor invasion and lymph node metastasis in ampullary cancer. Thus, FDG-PET can be a useful modality for preoperative staging and treatment strategy.

Conversion surgery for metastatic gastric cancer at 2 years after initial diagnosis of cancer of unknown primary with metastasis of cervical lymph nodes and ovary: a case report.

BACKGROUND: Patients with stage IV gastric cancer have a poor prognosis despite improvements in intensive treatment regimens, including chemotherapy. Recently, conversion surgery has received much attention as it can provide long-term survival in stage IV gastric cancer patients who are responsive to chemotherapy. Herein, we describe the case of a patient who underwent conversion surgery for metastatic gastric cancer that was performed over 2 years after an initial diagnosis of cancer of unknown primary (CUP) with metastasis of the cervical lymph nodes and the ovary. CASE PRESENTATION: A 67-year-old woman with cervical lymphadenopathy was referred to our hospital. Computed tomography showed left cervical lymphadenopathy and bilateral ovarian enlargement. Endoscopic survey revealed no signs of malignancy in the upper or the lower gastrointestinal tract. Pathological findings after cervical lymphadenectomy revealed a signet-ring cell carcinoma and were suggestive of gastric cancer metastases. However, multiple evaluations yielded no evidence of gastric cancer and the patient was diagnosed with CUP. She was prescribed chemotherapy for gastric cancer and underwent bilateral oophorectomy after undergoing chemotherapy for 18 months. Pathologic analysis of oophorectomy tissue revealed findings identical to those seen in the cervical lymph nodes. At about 2 years after the initial diagnosis, an esophagogastroduodenoscopy revealed evidence of gastric cancer. We performed a distal gastrectomy with D2 lymphadenectomy. Her postoperative course was uneventful and she remains alive with no signs of disease recurrence at 3 months post-surgery. CONCLUSIONS: To the best of our knowledge, this is the first report describing successful conversion surgery for stage IV gastric cancer in a patient whose cancer was definitively diagnosed 2 years after an initial diagnosis of CUP.

Four stay-sutures method: a simplified hand-sewn purse-string suture in laparoscopic circular-stapled esophagojejunostomy.

Laparoscopic esophagojejunostomy is a challenging procedure because of its technical difficulty. We herein report a new method involving circular-stapled anastomosis using a hand-sewn suture with four stay-sutures and evaluate its outcomes. Esophagojejunostomy using this method was performed in 36 consecutive patients with clinical stage I gastric cancer at the authors' institutions. The key feature of our procedure was the placement of four full-thickness stay-sutures to anchor the esophageal stump prior to the hand-sewn purse-string suture. The median operation time and mean anvil fixation time were 315.5 and 21.9 min, respectively. The mortality rate was 0%, although anastomotic leakage following esophagojejunostomy was observed in 1 patient (2.8%), and anastomotic stenosis was observed in another patient (2.8%). Intracorporeal esophagojejunostomy using the four stay-sutures method appears to be safe and feasible. We believe that this method enables hand-sewn purse-string suturing to be performed more easily.

Neuroendocrine tumor of the ampulla of Vater with distant cystic lymph node metastasis: a case report.

BACKGROUND: Neuroendocrine tumors (NETs) of the ampulla of Vater are rare and difficult to diagnose. We report a rare case of a small NET of the ampulla of Vater with metastasis to distant lymph nodes. CASE PRESENTATION: The patient was a 54-year-old man complaining of epigastric pain and melena. Upper gastrointestinal endoscopy revealed a bulging papilla with active bleeding, which was diagnosed as a well-differentiated NET of the ampulla of Vater. An approximately 10-mm hypervascular tumor at the ampulla of Vater and a 41-mm cyst adjacent to the wall of the jejunum were revealed by abdominal computed tomography. We performed pylorus-preserving pancreaticoduodenectomy with lymph node dissection. Macroscopic examination revealed a 9-mm tumor of the ampulla of Vater and a 52-mm cyst adjacent to the wall of the jejunum. Histological examination revealed that the cyst was a lymph node metastasis. The final diagnosis was non-functional NET G1 of the ampulla of Vater, designated T1N1M0 stage IIIB. Postoperatively, the patient underwent no treatment and has had no recurrence for 4 years. CONCLUSIONS: This case demonstrates that sporadic NETs of Vater's papilla have aggressive metastatic potential even with a small primary lesion, and radical resection with lymphadenectomy is recommended for all cases.

Relationship between functional end-to-end anastomosis for colon cancer and surgical site infections.

PURPOSE: Surgical site infections (SSI) are a common complication of gastrointestinal tract surgery. In this study, we explored the correlation between the anastomosis method and the incidence of SSI. METHODS: A total of 110 patients underwent ileocecal resection or right hemicolectomy for the excision of colon cancer. Two methods (open and closed, 28 and 82 patients, respectively) of functional end-to-end anastomosis were adopted. RESULTS: Increased perioperative blood loss (p = 0.029214), a longer hospital stay (p = 0.026668) and the development of SSI (p = 0.000181) were significantly correlated with the open method. There was no correlation between SSI and the body mass index, or between SSI and the length of the surgery or diabetes mellitus. However, patients that developed SSI tended to be obese. CONCLUSION: The open method was associated with a higher incidence of SSI. Therefore, it is necessary to consider potential contamination of the surgical field at the time of anastomosis to reduce the incidence of SSI.

Forkhead box protein C2 contributes to invasion and metastasis of extrahepatic cholangiocarcinoma, resulting in a poor prognosis.

Extrahepatic cholangiocarcinoma (EHCC) is a cancer with a poor prognosis, and the postoperative survival of patients depends on the existence of invasion and metastasis. The epithelial-to-mesenchymal transition (EMT) is an important step in EHCC invasion and metastasis. Forkhead box protein C2 (FOXC2) is a transcription factor that has been reported to induce the EMT. Therefore we examined the correlation between FOXC2 expression and clinical pathological factors, and analysed the function of FOXC2. The expression of FOXC2 in 77 EHCC cases was investigated by immunohistochemical staining, and the relationship between FOXC2 expression and clinicopathological factor was assessed. Knockdown by small interfering RNA (siRNA) was performed to determine the roles of FOXC2 in EHCC cell line. FOXC2 expression correlated with lymph node metastasis (P = 0.0205). Patients in the high FOXC2 expression group had a poorer prognosis than the patients in the low FOXC2 expression group. Moreover, FOXC2 knockdown inhibited cell motility and invasion, and decreased the expression of EMT markers (N-cadherin, and matrix metalloproteinase (MMP) -2) and Angiopietin-2 (Ang-2). The EMT inducer FOXC2 contributes to a poor prognosis and cancer progression. FOXC2 may be a promising molecular target for regulating EHCC metastasis.

An individual with gastric schwannoma with pathologically malignant potential surviving two years after laparoscopy-assisted partial gastrectomy.

Schwannomas are a kind of neurogenic tumor. They are generally benign and originate primarily from the central and peripheral nerve. They rarely develop in the gastrointestinal tract: gastric schwannomas make up 0.2% of gastric neoplasms. A malignant gastric schwannoma is a comparatively rare tumor, a few cases have been reported until now. We present the case of a 34-year-old male patient diagnosed during medical examination. The patient was treated with surgical resection, and 2 years passed without recurrence.

[Preventive effect of aprepitant, an oral NK1 receptor antagonist, on acute and delayed chemotherapy-induced nausea and vomiting for colorectal cancer].

A standard therapeutic regimen of a 5-HT3 receptor antagonist antiemetic agent+dexamethasone was administered as antiemetic therapy for 29 patients who received chemotherapy for colorectal cancer in the Department of Surgery at Gunma Saiseikai Maebashi Hospital, from January to March 2010. For 13 patients with delayed nausea, the therapy was changed to an aprepitant regimen (aprepitant+5-HT3 receptor antagonist antiemetic agent+dexamethasone)to evaluate the preventive effect of aprepitant on acute and delayed nausea and vomiting. This aprepitant regimen produced a significant improvement in the primary endpoint, based on a complete response (CR) of no vomiting and no rescue treatment throughout the administration period, and in the secondary endpoint of CR in the delayed phase, with no delayed nausea. In addition, a tendency for improvement was found in other secondary endpoints: complete protection (CP) based on no vomiting, no rescue treatment, and no significant nausea throughout the observation period; no vomiting; and no significant nausea. These findings suggest that using aprepitant as an antiemetic therapy during chemotherapy for colorectal cancer may be effective for patients with nausea and vomiting that are intractable to standard therapeutic regimens.

Liver hemorrhage due to idiopathic peliosis hepatis successfully treated with hepatic artery embolization.

Peliosis hepatis is an extremely rare condition that may cause fatal hepatic hemorrhage and liver failure. We report a case of liver hemorrhage due to idiopathic peliosis hepatis. A 60-year-old woman was admitted to our hospital with slight right hypochondriac pain. She went into hemorrhagic shock, and computed tomography (CT) showed multiple low-density areas in the right liver with massive subcapsular blood collection. Selective transfemoral arteriography of the celiac artery revealed no signs of vascular malformation or tumor stain, but showed signs of pooling in the right posterior segmental artery. The artery was embolized with particles of gelatin sponge, and hemostatic control was successful. Although peliosis hepatis is extremely rare, the diagnosis is significant because of its urgent clinical status, and transarterial embolization is a useful and minimally invasive procedure for liver hemorrhage due to peliosis hepatis.

Overexpression of Cap43 is associated with malignant status of esophageal cancer.

Cap43 protein has been proven to be upregulated by nickel compounds or hypoxic stress, often during cell differentiation or cell growth arrest. However, the function of this gene remains unknown. Although, several studies have been performed, none of these have evaluated the expression of Cap43 in esophageal cancer. To clarify its function and role in esophageal cancer, a clinical archive of cancer specimens was examined for the expression of Cap43 by immunohistochemistry. The expression level of Cap43 protein was also investigated by Western blotting and mRNA by realtime RT-PCR using esophageal cancer cell lines. Immunohistochemistry results showed that overexpression of Cap43 was correlated with malignant status of esophageal cancer and that was considered as an independent prognostic marker. Interestingly, adenocarcinoma of the esophagus did not express Cap43. In esophageal cancer cell lines, Western blotting and real-time RT-PCR, showed a variation in the expression level of Cap43 and there was no obvious correlation between protein and mRNA levels. The present report shows for the first time that the expression of the Cap43 gene has a function in tumor progression and that its expression correlates independently with patient survival. Cap43 gene could be considered as a new and important cancer marker.

Laparoscopic cholecystectomy using a novel two-port technique for surgical residency training.

For the cosmetic benefits of patients, many institutions attempted to perform laparoscopic cholecystectomy (LC) with a minimum port. It has not yet been discussed whether the number of ports used in LC affect an outcome in a residency training program. We enrolled 101 patients consecutively. Eight freshmen (PGY1) performed 32 operations (13 cases with two-port, 23 cases with four-port). Clinical data were compared with the data by the senior staff. In the freshman group, the duration of surgery was longer in the two-port group than in the four-port group (P = 0.0297); however, there were no complications. In the two-port group, the freshman group took longer than the senior group (P = 0.0266). As for the volume of intraoperative bleeding, there was no statistical significance. Our two-port technique seems to be a feasible, effective, and safe technique for performing LC in the residency training program on selected patients.

Macrocystic serous cystadenoma mimicking branch duct intraductal papillary mucinous neoplasm.

A 29-year-old woman was referred to our hospital with a pancreatic cystic tumor diagnosed by computed tomography and magnetic resonance imaging. Endoscopic retrograde cholangiopancreatography was performed, wherein macrocystic serous cystadenoma of the pancreas was diagnosed. It was decided to observe the progress of the disease. The tumor diameter increased over 18 months to > 50 mm. Its growth rate was slower than the average rate of serous cystadenoma described in previous reports, but its form become warped and shaped like bunches of grapes. A branch duct variant of intraductal papillary mucinous neoplasm could not be excluded. Laparoscope-assisted distal pancreatectomy was performed, and the pathological diagnosis was macrocystic serous cystadenoma. Some macrocystic serous cystadenomas are like an intraductal papillary mucinous neoplasm, and differential diagnosis is very difficult. The macrocystic serous cystadenoma is a rare lesion, but it should be considered when diagnosing cystic tumors of the pancreas.

Peptides derived from a soluble molecule of the human leukocyte antigen (HLA) class I cause apoptosis in gastric cancer cell lines.

We have reported that the levels of the soluble molecule of the human leukocyte antigen class I (sHLA-I) in patients with advanced gastric cancer were significantly lower than those in patients with cancer in the early stages. However, the effect of sHLA-I on gastric cancer cells has not been elucidated. Using human gastric cancer cell lines, MKN28, MKN45, and MKN74, we evaluated the effects of sHLA-I on cell growth, DNA synthesis, and apoptosis induction. Three types of synthesized peptides derived from HLA-I were also examined for their capacity to induce apoptosis. sHLA-I and a synthesized peptide, nos. 220-232 of the alpha3 domain of HLA-B7, caused cell growth inhibition by inducing apoptosis in human gastric cancer cells. This peptide also inhibited the in vivo growth of cancer dissemination caused by an intraperitoneal injection of MKN45 into severe combined immunodeficient mice. In conclusion, sHLA-I and the peptides derived from HLA-I cause apoptosis in human gastric cancer cell lines.

The effect of hyperbaric oxygen treatment on postoperative morbidity of left lobe donor in living donor adult liver transplantation.

BACKGROUND/AIMS: In living donor liver transplantation (LDLT), donor safety has top priority, and donor morbidity should be minimized to zero. However, several corporal problems still remain. The effect of hyperbaric oxygenation treatment (HBO) was evaluated for donor morbidity in LDLT. METHODOLOGY: A total of 14 consecutive donors were studied. The donors into were divided into 2 groups as follows: HBO group (n=7), which started HBO 3 days after operation, and a control group (n=7). Patient's factors, graft volume, liver regeneration rate, liver function tests and postoperative complications ware compared between the 2 groups. RESULTS: There was no significant difference between the groups in whole liver, graft and remnant liver volume. The incidence of wound numbness on POD 28 was 86% (6/7) in the control group and 29% (2/7) in the HBO group (p<0.05). Postoperative hospital stay was 14.4 and 14.6 days in the control and HBO group, respectively (p=NS). On POD 14, AST value in the HBO group was significantly lower than in the control group (p<0.05). PT% value in the HBO group was significantly higher than in the control group on POD 14 (p<0.05). Total bilirubin level in the HBO group was significantly lower than in the control group on POD 14 and 28 (p<0.05), and total bile acid value in the HBO group was significantly lower than the control group (p<0.05) on POD 14. Albumin level in the HBO group was significantly higher than the control group on POD 7, 10 and 28 (p<0.05). Four weeks after the operation, the regeneration rate was significantly higher in the HBO group than in the control group (p<0.05). CONCLUSIONS: Liver regeneration was promoted by HBO preserving a function in LDLT using left lobe graft. Hyperbaric oxygen therapy seems to be very useful to LDLT.

Lymphoepithelial cyst of the pancreas: report of a case.

The aim of this report is to describe the clinical and pathological features of a lympoepithelial cyst of the pancreas and to recommend fine-needle aspiration biopsy for the differential diagnosis of this lesion. A 55-year-old man was incidentally diagnosed as having a pancreatic tumor by abdominal ultrasonography. A hypoechoic cystic lesion was detected on the surface of the pancreatic body. A computed tomography revealed a cystic lesion surrounded by a smooth, flat wall. Magnetic resonance imaging revealed that the lesion was a low-intensity mass on the T1-image and a slightly high-intensity mass on the T2-image. The lesion was diagnosed as a benign cystic tumor, and enucleation of the tumor was scheduled. The fine needle aspiration biopsy was performed after laparotomy, and cytology of the contents was negative for malignant cells. The postoperative pathological diagnosis was a lymphoepithelial cyst of the pancreas. This cyst is an unusual but benign mass that requires minimal surgery.

Is an elderly recipient a risk for living donor adult liver transplantation?

BACKGROUND/AIMS: In cadaveric liver transplantation, it has been reported that elderly recipients over 60 years are at risk because of high incidence of complication and malignancy. However, in living-donor adult liver transplantation (LDALT), it is unclear whether the elderly recipient is risky or not risky. In this study, the outcome after LDALT of elderly patients has been evaluated. METHODOLOGY: One hundred twenty two consecutive LDALT recipients were studied. The recipients were divided into an elderly group (older than 60 yrs, n = 21), and a control group (younger than 60 yrs, n = 101). Comparative examination of background factors, postoperative complications and de novo malignancy was carried out. RESULTS: Elderly patients more frequently received transplantation for hepatocellular carcinoma. Pretransplant liver damage such as Child-Pugh, MELD or bilirubin level was same among the groups. There was no significant difference in posttransplant complications except renal failure. Postoperative renal failure (postoperative creatinine level over 2mg/dL) occurred in 29% (n = 5) of the elderly group vs. 8% (n = 6) of the control group. De novo malignancy occurred in 1 case (lung) in the elderly group and 1 case (Vater) in the control group. In the control group, the 1, 3 and 5 year patient survival rates were 78.5%, 73.1% and 71.4%, respectively. And in the elderly group, the 1, 3 and 5 year patient survival rates were 85.7%, 81.0% and 70.8%, respectively. CONCLUSIONS: It may be, we concluded that living donor adult liver transplantation is good treatment for end stage liver diseases in elderly recipients over 60 years. However caution should be taken in the administration of medicine, including immunosuppressants or antibiotics, do to a propensity for postoperative renal failure in elderly recipients.

Primary liver cancers with nonalcoholic steatohepatitis.

Nine patients with hepatocellular carcinoma (HCC) in nonalcoholic steatohepatitis (NASH) (six men and three women, median age 71.5 years) and one patient with intrahepatic cholangiocarcinoma (ICC), a 50-year-old man, in NASH are described. Most patients were associated with obesity, diabetes, hypertension, hypercholesterolemia, or hypertriglyceridemia. Seven patients showed insulin resistance and hyperinsulinemia. All patients except one met the criteria for metabolic syndrome. An HCC or ICC diagnosis was confirmed by tumor biopsy, surgery or autopsy except in two patients, who were diagnosed by computed tomography or hepatic angiography. The underlying liver disease was liver cirrhosis in six patients and chronic liver disease including mild hepatic fibrosis in four patients. The treatment of liver cancers consisted of surgery, radio-frequency ablation (RFA), transcatheter arterial embolization and transcatheter arterial infusion. Although the follow-up period was relatively short (median 27.5 months, average 32.1 months), all postoperative and post-RFA patients have not had a recurrence of HCC to date, except for one patient who had a palliative operation with intra-arterial infusion of anticancer drugs through an implanted reservoir port. Older age and liver cirrhosis are considered risk factors for HCC in NASH, and regular screening of these patients is necessary. Diabetes may contribute to the development of ICC in NASH. Curative therapy (surgery or RFA) and weight loss by the active therapeutic intervention (nutritional care and exercise therapy) after curative therapy may help us improve the prognosis of HCC in NASH.

Preoperative endoscopic pancreatic stenting for prophylaxis of pancreatic duct disruption during extirpation of a pancreatic head tumor.

BACKGROUND: Pancreatic fistula is a major problem in minimal invasive surgery of the pancreas. To prevent the disruption of the pancreatic duct, the surgeon must recognize the site of the pancreatic duct exactly. METHODS: We reviewed the cases of 7 patients who underwent preoperative endoscopic pancreatic stenting for the prophylaxis of pancreatic fistula development after enucleation of a benign pancreatic head tumor. RESULTS: Preoperative endoscopic pancreatic stenting was successfully performed in all 7 patients. The level of serum amylase increased to 1500 IU/L on postoperative day 1, but levels recovered to normal within 3 days. None of the patients developed a pancreatic fistula. CONCLUSIONS: Preoperative pancreatic duct stenting is a feasible, effective, and safe technique to prevent pancreatic duct disruption during enucleation of a benign tumor of the pancreatic head.

Treatment of multiple liver metastasis from gastric carcinoma.

BACKGROUND: The efficacy of operative resection of liver metastasis from colorectal cancer has been established. However, a treatment for liver metastasis from gastric cancer has not yet been established. In this study, we evaluated the efficacy of hepatic arterial infusion for synchronous hepatic metastasis from gastric cancer. PATIENTS AND METHODS: This study consisted of 37 patients [HAI group; 18 and non-HAI group; 19] with synchronous multiple liver metastases from gastric cancer at Gunma Prefecture Saiseikai-Maebashi Hospital. We retrospectively analyzed the efficacy of HAI. RESULTS: Response rate (CR + PR) of HAI was 83%. However, HAI treatment did not affect any improvement in the survival rate. CONCLUSION: HAI is an effective treatment for control of liver metastasis specifically. The factor effective for an improvement in the survival rate was possibly that of gastrectomy.