The advantage of laparoscopic surgery in the treatment of Spigelian hernia: A report of two cases.

INTRODUCTION AND IMPORTANCE: The usefulness of laparoscopic surgery in the treatment of Spigelian hernias and the appropriate insufflation pressure remains unclear. CASE PRESENTATION: Case 1 involved an 81-year-old woman presented with a right abdominal protrusion. CT scan demonstrated a defect in the abdominal wall at the lateral edge of the right rectus abdominis muscle. We diagnosed as Spigelian hernia and performed laparoscopic hernia repair. The insufflation pressure was set at 10 cm H 2 O, and the IPOM method was selected as the repair method. Case 2 involved a 74-year-old male presented with a right abdominal painful bulging. Strangulation was released and CT scan demonstrated a defect in the abdominal wall at the lateral edge of the right rectus abdominis muscle. We diagnosed as Spigelian hernia and performed laparoscopic hernia repair. The insufflation pressure was set at 10 cmH 2 O, and the repair was performed by the hybrid method. CLINICAL DISCUSSION: In both cases, the positions of the hernia portals marked preoperatively based on the tender areas and confirmed laparoscopically were not accurate. Although Spigelian hernia is a rare disease and various laparoscopic techniques have been reported in recent years, laparoscopic surgery is very useful to obtain an accurate diagnosis and to observe the abdominal wall from inside the abdominal cavity under insufflation, and it is better to decide the repair method according to the situation of each case and institution. CONCLUSION: Laparoscopic surgery is important for accurate diagnosis in surgery of Spiegel's hernia, and insufflation pressure of 10 cmH2O was sufficient.

Necrotizing soft tissue infection of the thigh associated with retroperitoneal abscess in a patient with locally advanced ascending colon cancer: A case report.

Necrotizing soft tissue infection (NSTI) is a rare but rapidly progressing soft-tissue infection. Few reports of NSTI caused by colon cancer have been published. We present a rare case of NSTI of the thigh associated the retroperitoneal spread of ascending colon cancer. A 64-year-old man had noticed right hip pain since 3 months before admission, he felt pain in the right thigh which was reddening, and he had difficulty in walking. He was referred to Yokosuka general hospital Uwamachi. Anterolateral aspect of his right thigh was reddening and swelling. The patient was diagnosed with a psoas abscess and a NSTI of the right thigh caused by penetration of ascending colon tumor. The patient underwent debridement of severely necrotized tissue in the right thigh, diverting ileostomy and subsequently a right hemicolectomy with reversal of the ileostomy were performed. He was discharged 70 days after the first surgery. Colon cancer can be a cause of retroperitoneal abscess accompanied by NSTI of the thigh. Two-stage surgery was an efficient option in this patient with NSTI of the thigh associated with locally advanced ascending colon cancer.

Successful treatment with hyperbaric oxygen therapy for pneumatosis cystoides intestinalis as a complication of granulomatosis with polyangiitis: a case report.

BACKGROUND: Although gastrointestinal involvement in patients with granulomatosis with polyangiitis is uncommon, it is associated with mild to severe life-threatening complications. We present a case of pneumatosis cystoides intestinalis in a patient with granulomatosis with polyangiitis that was treated successfully with hyperbaric oxygen. CASE PRESENTATION: A 70-year-old Japanese man with a 3-year history of granulomatosis with polyangiitis consulted our hospital with a complaint of severe back pain. Computed tomography showed a large amount of gas located in his bowel wall and mesentery. He underwent urgent exploratory laparotomy, which led to a diagnosis of pneumatosis cystoides intestinalis without intestinal perforation or necrosis. He consequently underwent 13 sessions of hyperbaric oxygen therapy and was discharged from our hospital without complications. CONCLUSIONS: Several previous reports have supported the efficacy of hyperbaric oxygen for treating pneumatosis cystoides intestinalis. The present case, however, is the first in which pneumatosis cystoides intestinalis in a patient with granulomatosis with polyangiitis was successfully treated with hyperbaric oxygen. We therefore suggest that hyperbaric oxygen therapy could be a candidate treatment for pneumatosis cystoides intestinalis in patients with granulomatosis with polyangiitis.

Toxic shock syndrome caused by suture abscess with methicillin-resistant Staphylococcus aureus (MRSA) with late onset after Caesarean section.

Toxic shock syndrome (TSS) is a rare but life-threatening multisystem disease known to develop in the early postoperative period after various surgery. We report a rare case in which a patient who underwent Caesarean section developed TSS caused by methicillin-resistant Staphylococcus aureus (MRSA) on the 39th postoperative day. She was treated with debridement because of the possible diagnosis of necrotizing soft tissue infections. Culture test from the resected specimen was positive for MRSA. She was diagnosed with TSS caused by suture abscess and was treated with intensive care including antimicrobials. After a good postoperative course, she was discharged on the 30th postoperative day. TSS occurring 4 weeks after operation is extremely rare, but late-onset of suture abscess is known to occur. We should becognizant of development with TSS beyond early postoperative period.

Ascending colon cancer associated with deposited ova of Schistosoma japonicum in non-endemic area.

Some reports suggest the positive correlation between Schistosoma japonicum infection and colorectal cancer, however the sufficient evidence that supports a causal relationship between them has not been established. Japan used be an endemic area of S. japonicum infection for 40 years ago. But now all of Japan is a non-endemic area of S. japonicum infection. We report a case of ascending colon cancer associated with deposited ova of S. japonicum in non-endemic area.

Flare-Up Diverticulitis in the Terminal Ileum in Short Interval after Conservative Therapy: Report of a Case.

Diverticulitis in the terminal ileum is uncommon. Past reports suggested that conservative therapy may be feasible to treat terminal ileum diverticulitis without perforation; however, there is no consensus on the therapeutic strategy for small bowel diverticulitis. We present a 37-year-old man who was referred to our hospital for sudden onset of abdominal pain and nausea. He was diagnosed with diverticulitis in the terminal ileum by computed tomography (CT). Tazobactam/piperacillin hydrate (18 g/day) was administered. The antibiotic treatment was maintained for 7 days, and the symptoms disappeared after the treatment. Thirty-eight days after antibiotic therapy, he noticed severe abdominal pain again. He was diagnosed with diverticulitis in terminal ileum which was flare-up of inflammation. He was given antibiotic therapy again. Nine days after antibiotic therapy, laparoscopy assisted right hemicolectomy and resection of 20 cm of terminal ileum were performed. Histopathology report confirmed multiple ileal diverticulitis. He was discharged from our hospital 12 days after the surgery. Colonoscopy was performed two months after the surgery and it revealed no finding suggesting inflammatory bowel disease. Surgical treatment should be taken into account as a potential treatment option to manage the diverticulitis in the terminal ileum even though it is not perforated.

Nonocclusive mesenteric ischemia associated with ogilvie syndrome.

Nonocclusive mesenteric ischemia (NOMI) is one type of acute mesenteric ischemia. Colonic pseudoobstruction, known as Ogilvie syndrome, is a disorder defined by colonic distension in the absence of mechanical obstruction. A relationship between these diseases has not yet been reported, based on a review of the literature. We report a patient with NOMI secondary to Ogilvie syndrome. An 82-year-old woman reported three days of intermittent abdominal pain. Plain computed tomography scan showed colonic obstruction at the rectosigmoid colon. Colonoscopy was performed that showed a large amount of stool and no evidence of tumor or other physical causes of obstruction. We diagnosed the patient with Ogilvie syndrome and continued nonoperative management. On the third hospital day, she complained of abdominal distension. A repeat CT scan showed pneumatosis intestinalis in the small bowel and ascending colon, with portal venous gas. Emergency laparotomy was performed with diagnosis of mesenteric ischemia. Intraoperatively, there were multiple skip ischemic lesions in the small intestine and cecum. We resected the ischemic bowel and performed a distal jejunostomy. Her residual small bowel measured just 20 cm in length. Postoperatively, her general status gradually improved. She was discharged with total parenteral nutrition and a small amount of enteral nutrition.

Duodenal fistula associated with a peri-appendiceal abscess: A case report.

INTRODUCTION: Retroperitoneal abscess is an unusual presentation of perforated appendicitis. A fistula between the duodenum and an abscess resulting from appendicitis has not been previously reported. PRESENTATION OF CASE: A 53-year-old Japanese man with a past medical history of hypertension and iron deficiency anemia presented with a 10-day history of fever and right lower abdominal pain, and was diagnosed with a retroperitoneal abscess secondary to perforated appendicitis. He was then treated with piperacillin and tazobactam after undergoing ultrasound-guided drainage, after which his overall condition improved. Due to iron deficiency anemia, we performed further evaluation for gastrointestinal bleeding and esophagogastroduodenoscopy showed an elevated lesion with granulomatous tissue in the duodenum, without an associated ulcer. At 10 days after abscess drainage, duodenography with contrast showed continuity between the abscess cavity and the duodenum. At 74 days after drainage, we performed laparoscopic appendectomy. Pathological examination showed granulomatous tissue inside the appendix with an inflammatory background and fecaliths infiltrated by macrophages. DISCUSSION: Perforated appendicitis has various presentations and many unusual fistulae have been reported, however, a fistula between a peri-appendiceal abscess and the duodenum has not yet been reported. A retroperitoneal abscess around the duodenum and appendix should be checked to differentiate it from Valentino's syndrome. CONCLUSION: We present the rare complication of a duodenal fistula during the treatment of perforated appendicitis. The possibility of fistula formation should be considered in patients with complicated appendicitis.

The accumulation of DNA demethylation in Sat α in normal gastric tissues with Helicobacter pylori infection renders susceptibility to gastric cancer in some individuals.

Helicobacter pylori (HP) infection is widely recognized as a risk factor for gastric cancer, but only a minority of infected individuals develop gastric cancer. The aim of this study was to determine whether DNA demethylation in non-cancerous gastric mucosa (NGM) significantly enhances susceptibility to gastric cancer. A total of 165 healthy volunteers, including 83 HP-positive and 82-negative individuals, as well as 83 patients with single and 18 with synchronous double gastric cancer (GC) were enrolled in this study. The relative demethylation levels (RDLs) of repetitive sequences, including Alu, LINE-1 and Sat α, were quantified by real-time methylation-specific polymerase chain reaction. The Alu RDL did not exhibit any differences within each respective group, whereas LINE-1 RDL was significantly elevated in cancer tissues compared with the NGM in the other groups (P<0.001). Our results indicated that a gradual increase in Sat α RDL correlated with HP infection and cancer development. Sat α RDL was significantly elevated in the NGM in HP-positive compared with HP-negative (P<0.001), and significantly elevated in cancer tissues (P<0.001). Although the Sat α RDL of the NGM in the total population increased in an age-dependent manner, it was significantly increased in a fraction of younger GC patients (<45 years) compared with all of the others (45 years or older, P=0.0391). In addition, double GC exhibited a significantly higher Sat α RDL in the NGM compared with single GC (P=0.0014). In these two fractions, Sat α RDL in the NGM exhibited an inverse correlation with age. In conclusion, the present study demonstrated that the accumulation of DNA demethylation in Sat α RDL in the NGM with HP infection potentially renders susceptibility to gastric cancer in a fraction of GC patients younger than 45 years or in patients with multiple cancers.

Aberrant methylation of the Pleckstrin and Sec7 domain-containing gene is implicated in ulcerative colitis-associated carcinogenesis through its inhibitory effect on apoptosis.

The Pleckstrin and Sec7 domain-containing (PSD) gene, which regulates skeletal rearrangements, has been found to be more frequently methylated both in ulcerative colitis (UC)-associated colorectal cancer tissues (5 of 7; 71.4%) and matched normal epithelia (4 of 7; 57.1%) compared to non-neoplastic UC epithelia (6 of 22; 27.3%) and sporadic colorectal cancer tissues (6 of 32; 18.8%). The levels of PSD mRNA were positively correlated with the methylation status of PSD, as shown by both MSP and bisulfite sequencing. To determine the potential role of PSD silencing in the mechanisms underlying UC-associated carcinogenesis, the levels of senescence, proliferation and apoptosis were evaluated in a normal human fibroblast cell line (NHDF) in which 93% of PSD expression was knocked down by a small-interfering RNA (si-RNA). Although there were no significant differences in the levels of senescence and proliferation caused by PSD knockdown, the level of apoptosis was significantly decreased by PSD knockdown (5.3% in siControl-treated cells vs. 0.67% in siPSD-treated cells, p=0.0001). In addition, reactive oxygen species inducers accelerated apoptosis in NHDF and a neutrophil-like cell line, which was significantly reduced by PSD knockdown. To verify the effect of PSD methylation in tissue sections including 21 samples from UC patients with or without tumors, we elucidated PSD promoting accumulation of filamentous-actin (F-actin) and apoptosis by immunohistochemistry and TUNEL assay, respectively. Both levels of accumulation of F-actin and apoptosis were significantly decreased in specimens from UC patients with PSD methylation compared to those without PSD methylation (F-actin: 0.69±0.86 with vs. 1.57±0.51 without, p=0.0031, apoptotic index: 0.31±0.63 with vs. 1.0±0.88 without, p=0.0277). In conclusion, our results indicate that PSD methylation plays a significant role in the mechanisms underlying UC-associated carcinogenesis through its inhibitory effect on apoptosis in the interaction between colorectal mucosa and neutrophils.

Aberrant methylation of PSD disturbs Rac1-mediated immune responses governing neutrophil chemotaxis and apoptosis in ulcerative colitis-associated carcinogenesis.

We previously reported that the Pleckstrin and Sec7 domain-containing (PSD) gene is preferentially methylated in patients with ulcerative colitis (UC) who developed colorectal cancer (CRC), and is implicated in UC-associated carcinogenesis through its inhibition of apoptosis. This study aimed to determine the potential effect of PSD methylation on its downstream molecule, Ras-related C3 botulinum toxin substrate 1 (Rac1), which governs neutrophil chemotaxis and apoptosis signaling. PSD was knocked down in a normal human fibroblast cell line (HNDF) and a neutrophil-like cell line (HL-60). Both NHDF and HL-60 cells exhibited numerous filamentous-actin (F-actin) rich membrane extensions, resulting in the activation of Rac1; this activation was hampered by PSD silencing. Lipopolysaccharide, a reactive oxygen species (ROS) inducer, stimulated NHDF cells to release ROS and activated caspase­3/7 in the presence of neutrophils, which was inhibited by PSD knockdown. Migration assays demonstrated that chemotaxis of HL-60 cells was affected by PSD silencing in NHDF cells. Tissue sections from 6 UC patients with CRC and 15 UC patients without CRC were examined. To verify Rac1-mediated chemotaxis in tissue sections, we evaluated the grade of neutrophil infiltration by histological assessment and assessed F-actin and PSD expression by immunohistochemistry. Neutrophil infiltration, F-actin and PSD expression were significantly decreased in specimens from UC patients with PSD methylation compared with those without. Decreased levels of F-actin expression were observed in colorectal mucosa, as well as in infiltrating cells with PSD methylation. PSD expression was preferentially inhibited in colorectal mucosa by PSD methylation, whereas PSD expression was rarely observed in infiltrating cells, regardless of PSD methylation status. These data indicate that aberrant methylation of PSD occurs in UC-associated colorectal mucosa, enabling circumvention of Rac1-mediated immune responses governing neutrophil chemotaxis and apoptosis, and thus plays a pivotal role in the mechanisms underlying UC-associated carcinogenesis.

Array-based identification of common DNA methylation alterations in ulcerative colitis.

Patients with long-standing ulcerative colitis (UC) have higher risk of developing colorectal cancer. Albeit the causes remain to be understood, epigenetic alterations have been suggested to play a role in the long-term cancer risk of these patients. In this work, we developed a novel microarray platform based on methylation-sensitive amplified fragment length polymorphism (MS-AFLP) DNA fingerprinting. The over 10,000 NotI sites of the human genome were used to generate synthetic primers covering these loci that are equally distributed into CpG rich regions (promoters and CpG islands) and outside the CpG islands, providing a panoramic view of the methylation alterations in the genome. The arrays were first tested using the colon cancer cell line CW-2 showing the reproducibility and sensitivity of the approach. We next investigated DNA methylation alterations in the colonic mucosa of 14 UC patients. We identified epigenetic alterations affecting genes putatively involved in UC disease, and in susceptibility to develop colorectal cancer. There was a strong concordance of methylation alterations (both hypermethylation and hypomethylation) shared by the cancer cells of the CW-2 cell line and the non-cancer UC samples. To the best of our knowledge, this work defines the first high-throughput aberrant DNA methylation profiles of the colonic mucosa of UC patients. These epigenetic profiles provide novel and relevant knowledge on the molecular alterations associated to the UC pathology. Some of the detected alterations could be exploited as cancer risk predictors underlying a field defect for cancerization in UC-associated carcinogenesis.

Granulocyte-colony-stimulating factor-producing gastric metastasis from large cell type lung cancer.

We report a case of granulocyte-colony-stimulating factor (G-CSF)-producing gastric metastasis from large cell type lung cancer. A 73-year-old man presented with severe anemia and leukocytosis that appeared 8 months after surgery for early lung cancer. Gastroendoscopy demonstrated a protruding circumscribed tumor with blood clot in the middle part of the stomach. The pathological finding from biopsy specimens revealed gastric metastasis of large cell carcinoma of the lung. Positron emission tomography/computed tomography demonstrated uptake in the bone; however, myeloid metastasis was negative with bone marrow biopsy. Serum level of G-CSF was elevated. We performed partial gastrectomy for hemostasis. After surgery, the hemoglobin, leukocyte count and serum level of G-CSF were within the expected normal limit. Immunohistological examination of G-CSF was positive in the resected specimen. The patient was discharged 22 days after the operation and has been followed up from 3 months after surgery to the present time. G-CSF-producing tumors have been reported to cause remarkable peripheral leukocytosis and neutrophil production in bone marrow. They have been reported in various types of malignancies and are usually associated with a poor prognosis.

Diagnostic accuracy of CT colonography and optical colonoscopy evaluated using surgically resected specimens.

OBJECTIVE: The aim of this study was to clarify the diagnostic ability of CT colonography (CTC) using surgically resected specimens to avoid inaccuracy associated with optical colonoscopy (OC). SUBJECTS AND METHODS: CTC and OC were performed in 152 consecutive patients with colorectal cancer. Forty patients had simultaneous lesions other than the ones for which the surgery was intended, and these lesions were used as the gold standard. In 24 patients without stenosis, the sensitivity and positive predictive values (PPV) of CTC and OC were evaluated. In 16 patients with stenosis, the diagnostic ability of CTC for lesions located proximal to the stenosis was assessed. RESULTS: Sensitivity of CTC and OC was 81% and 66% (P = 0.16), and PPV was 90% and 100% (P = 0.13), respectively. For 22 lesions larger than 5 mm, the sensitivity of CTC and OCS was 96% and 91% (P > 0.50), and PPV was 100% and 100%, respectively. In patients with stenosis, sensitivity and PPV were 89% and 80%, respectively. These results were not significantly different from those in patients without stenosis. CONCLUSIONS: CTC is a reliable modality for the diagnosis of colorectal polyps. It is also useful to evaluate the colon proximal to severe stenosis which could not be observed by OC.

[Intrathoracic infusion with a combination of low-dose minocycline, OK-432 and cisplatin for malignant pleural effusion].

We investigated the effectiveness and complications of intrathoracic infusion with a combination of cisplatin, OK-432, and minocycline for malignant pleural effusion. All patients were hospitalized with chest tube drainage of pleural effusion until the daily drainage volume was less than 100 ml. Twenty-five mg of minocycline, 1 to 3 KE of OK-432, and 5 to 10 mg of cisplatin were instilled into the pleural space. The administration was repeated until drainage effusion disappeared. Therapeutic effect was evaluated according to the following criteria: (1) excellent, no fluid reaccumulation for at least 4 weeks as determined by chest radiogram and clinical evaluation; (2) effective, fluid reaccumulation less than 50% of original effusion with no need of thoracentesis for symptomatic relief within 4 weeks after treatment; and (3) failure, reaccumulation of more than 50% of the original effusion requiring thoracentesis to relieve symptoms within 4 weeks of treatment. Twelve patients with malignant effusion received the combination treatment; 11 patients had primary lung cancer and one had metastatic lung tumor from cancer of the rectum. In all cases, the histology or cytology revealed adenocarcinoma. Eleven of the 12 patients had an excellent response with relief of clinical symptoms. The remaining case failed to show any improvement. Complications such as local pain, fever, nausea, and vomiting were mild and transient. We conclude that combination administration of low-dose minocycline, OK-432, and cisplatin into the thoracic cavity for malignant effusion is an effective alternative treatment with the potential for improvement of the general condition and reduced morbidity.

Orally active carbapenem antibiotics I. Antibacterial and pharmacokinetic potential of 2-phenyl and 2-thienylcarbapenems.

In order to design orally active carbapenem antibiotics effective against beta-lactam-resistant pathogens, such as penicillin-resistant Streptococcus pneumoniae (PRSP) and beta-lactamase non-producing ampicillin-resistant Haemophilus influenzae (BLNAR), a series of novel 2-phenylcarbapenems and some 2-thienyl derivatives were synthesized and tested for antibacterial activities. These compounds were highly active against PRSP, BLNAR, and major Gram-positive and Gram-negative bacteria that cause community-acquired infections. Their pivaloyloxymethylester-type prodrug exhibited good oral absorption in mice, suggesting that this series of carbapenems were promising as a prototype of novel orally active beta-lactams.

[Thoracoscopic surgery using a new bronchial blocker].

We report use of a new bronchial blocker through a single-lumen endotracheal tube to achieve one-lung ventilation to perform thoracoscopic operation in patients in whom placement of the double-lumen tube failed and difficult intubation is predicted. The bronchial blocker tube was placed into the aimed bronchus under the bronchoscopic vision and the cuff of the blocker was inflated to achieve one-lung ventilation. In all of the 4 patients, the bronchial blocker could be inserted and placed safely, quickly, and exactly under the fiberoptic flexible bronchoscopic vision to perform thoracoscopic operation without any complications. The new bronchial blocker tube through the indwelling endotracheal tube may have advantages in situations where placement of double-lumen endotracheal tubes is technically impossible or inappropriate. The use of the new bronchial blocker tube will, however, require careful evaluation in larger series.