[Laparoscopic repair of incarcerated diaphragmatic hernia as a late complication of laparoscopic right hepatectomy: a case report].

Incarcerated diaphragmatic hernia after laparoscopic right hepatectomy is very rare. An 81-year-old man underwent laparoscopic right hepatectomy for giant hepatic hemangioma. Twenty months after the surgery, he began to complain of nausea and abdominal pain and was brought to our hospital. Chest X-ray showed an abdominal gas shadow above the right diaphragm and computed tomography showed herniation of the colon into the right thoracic cavity. We diagnosed ileus due to incarcerated diaphragmatic hernia and performed emergency operation under laparoscopic surgery. After successfully reducing the prolapsed colon back to the abdominal cavity, the diaphragmatic hernia orifice was repaired. Incarcerated diaphragmatic hernia sometimes causes the fatal state. Clinicians must therefore consider such findings a late complication of laparoscopic hepatectomy.

Totally laparoscopic colectomy with intracorporeal anastomosis achieved using a laparoscopic linear stapler: experience of a single institute.

PURPOSE: Laparoscopic colonic surgery is now widely accepted. We assessed the safety and effectiveness of using a total intracorporeal surgical strategy to perform intracorporeal functional end-to-end anastomosis with an endoscopic linear stapler to treat colon cancer. METHODS: Forty-three selected patients underwent elective laparoscopic colon resection for carcinoma. A total intracorporeal colon resection was performed in all patients, using a functional end-to-end anastomosis with an endoscopic linear stapler. RESULTS: Good results were achieved in all 43 patients, none of whom required conversion to open surgery with extracorporeal anastomosis. There have been no intraoperative complications related to this technique and no instances of postoperative anastomotic leakage, intra-abdominal abscess, or wound infection. CONCLUSION: Intracorporeal functional end-to-end anastomosis using a linear stapler can be performed safely and easily for the resection of any part of the colon. We consider it an effective modality for totally laparoscopic colon resection. Favorable results have been achieved by this method, particularly for small tumors, since natural-orifice transluminal endoscopic surgery remains a challenging method to perform.

Peroral placement of a self-expandable covered metallic stent using an overtube for malignant gastroduodenal obstructions.

PURPOSE: To evaluate the technical feasibility and safety of overtube-guided covered metallic stent placement as palliative treatment for patients with inoperable malignant gastric outlet obstructions. METHODS: To relieve the symptoms of severe nausea and recurrent vomiting in five patients with inoperable gastric cancer, we used an overtube (Long overtube; Sumitomo Bakelite, Tokyo, Japan) to place large-diameter, self-expandable, covered esophageal Ultraflex stents (inner diameter 22-28 mm, length 10 or 12 cm; Boston Scientific, Watertown, MA, USA). Success was defined both technically and clinically. RESULTS: The stent placement was technically successful in all patients and resulted in improvement of symptoms in all five patients, four of whom were thereafter able to ingest solid food. The remaining patient, a 94-year-old man, was unable to ingest food because of dysmasesis. During the mean follow-up of 17 weeks, there was no stent reocclusion and no life-threatening complications developed. CONCLUSIONS: The placement of a large diameter, self-expandable, covered esophageal stent using an overtube appears to be effective for the palliative treatment of malignant gastric outlet obstruction.

Intraoperative cholangiography using an endoscopic nasobiliary tube during a laparoscopic cholecystectomy.

PURPOSE: The goals of this report are to present the characteristics of biliary complications associated with laparoscopic cholecystectomies (LC) performed at a single center, and to evaluate the efficacy of intraoperative cholangiography (IOC) using an endoscopic nasobiliary tube (ENBT) during an LC in order to prevent biliary complications. METHODS: A retrospective audit was conducted on a total of 657 patients who underwent either LC or open cholecystectomies (OC). There were 19 patients who developed bile duct injury (BDI; n = 9) or bile leakage (BL; n = 10) during an LC and were actively treated. After May of 1999, the patients with a higher risk of developing biliary complications were selected for preoperative placement of an ENBT, and IOC was performed. RESULTS: Intraoperative cholangiography using ENBT was performed on 93 (27.1%) out of 343 patients who underwent either LC or OC after May of 1999. An LC was performed in 335 cases (97.7%), and a conversion from an LC to OC was necessary in only three cases. Even though BDI never occurred, BL from the cystic duct and gallbladder bed were recognized in five cases. CONCLUSIONS: The selective use of IOC using ENBT may help to prevent BDI during LC, thereby expanding the indications for LC, while also reducing the rate of conversion to open procedures.

A randomized phase II trial of adjuvant chemotherapy with bi-weekly carboplatin plus paclitaxel versus carboplatin plus gemcitabine in patients with completely resected non-small cell lung cancer.

BACKGROUND: The benefits of adjuvant chemotherapy for completely resected non-small cell lung cancer (NSCLC) have been demonstrated using mainly cisplatin (CDDP)-based chemotherapeutic regimens. However, treatment-related deaths sometimes occur. Therefore, the development of a safer regimen is necessary. PATIENTS AND METHODS: The patients were randomized to either carboplatin (CBDCA) area under the curve (AUC) 3 and paclitaxel (PTX) 90 mg/m(2) (PCb arm) or CBDCA (AUC3) plus gemcitabine (GEM) (1000 mg/m(2)) (GCb arm) every 2 weeks for 8 cycles after surgery. The primary endpoint was the compliance with the regimen, while the secondary endpoints were safety and toxicity. RESULTS: A total of 75 patients were enrolled in a multi-institutional study. Twenty-one out of 39 patients (54%) in the PCb arm and 25 of 36 patients (69%) in the GCb arm completed 8 cycles, and 59% in the PCb arm and 81% in the GCb arm completed ≥6 cycles. The predominant toxicity was neutropenia. Non-hematological adverse effects were infrequent and no treatment-related death was registered. The estimated disease-free survival and overall survival at 2 years were 70.8% and 66.3% in the PCb and 91.4% and 79.1% in the GCb arm, respectively. CONCLUSION: This adjuvant bi-weekly scheduled chemotherapy resulted in good compliance in both arms, and the regimen was feasible, with acceptable levels of toxicity in completely resected Japanese NSCLC patients. Therefore, these regimens represent a new treatment option suitable for outpatients with completely resected NSCLC.

Curative surgery improves the survival of patients with perforating colorectal cancer.

PURPOSE: Colorectal cancers that manifest as a perforation are generally regarded as carrying a poor prognosis. We conducted this study to assess the outcome of colorectal cancer complicated by perforation. METHODS: Between 1996 and 2004, 848 patients underwent surgery for colorectal cancers in our department. We reviewed 22 (2.6%) consecutive patients who presented with perforation at one institution. RESULTS: Fifteen (69%) patients underwent potentially curative resection. The overall operative morbidity and mortality rates were 50% and 9%. The overall 5-year survival rate was 17.4%, although by excluding patients who either had stage IV disease at diagnosis or who died during or soon after surgery (n = 7), the 5-year survival rate increased to 32% (n = 15). Furthermore, the 5-year survival rate of patients who underwent a potentially curative resection (36.9%) was significantly better than that of those who underwent a noncurative resection (0%, P = 0.0093). CONCLUSIONS: Perforating colorectal cancers are associated with high postoperative mortality and poor long-term survival. However, the intensive management of radical lymph node dissection and surgical resection are recommended to improve the long-term prognosis.

Phase II trial of adjuvant chemotherapy with bi-weekly carboplatin plus paclitaxel in patients with completely resected non-small cell lung cancer.

BACKGROUND: Adjuvant chemotherapy improves the prognosis of patients with non-small cell lung cancer (NSCLC) after a complete resection despite unacceptable toxicity and low compliance. METHODS: A total of 67 patients were enrolled in a multi-institutional study. The patients received chemotherapy with carboplatin (CBDCA) area under the curve of 3 and paclitaxel (PTX) 90 mg/m(2) every 2 weeks for six cycles after surgery. RESULTS: Fifty patients (74.6%) completed all cycles of therapy. The presence of grade 3 and 4 toxicities of neutropenia were 13.4, and 3.0%, respectively. Non-haematological adverse effects were infrequent and no treatment-related death was registered. The estimated disease-free survival and overall survival at 2 years were 89.0% and 88.8%, respectively. CONCLUSION: A bi-weekly schedule of CBDCA and PTX as adjuvant chemotherapy showed an acceptable toxicity and favourable feasibility in Japanese NSCLC patients after complete tumor resection. Consequently, it is desirable to validate this regimen in a future randomized clinical trial.

Laparoscopic surgery for the diagnosis and treatment of a paracecal hernia repair: Report of a case.

Internal hernias are relatively rare viscous protrusions through a defect in the peritoneal cavity. Paracecal hernia is one of the least common types, and only a few cases have been reported to date. We herein present the case of a 43-year-old woman, who was preoperatively diagnosed to have a small bowel obstruction caused by a paracecal hernia resulting from intestinal protrusion and invagination into a paracecal pouch. Laparoscopic surgery was performed for definitive diagnosis and treatment. The surgery achieved a good outcome and the patient experienced an uneventful perioperative course.

Surgical treatment of cecal cancer in a patient with Glanzmann's thrombasthenia: report of a case.

Glanzmann's thrombasthenia (GT) is a rare inherited platelet disorder with no specific treatment. Prophylactic and therapeutic platelet transfusions work only as supportive treatments. To date, there has been no report of surgical treatment for malignant disease in GT patients. We herein report the case of a 43-year-old woman presenting with cecal cancer with accompanying GT. The patient underwent a laparotomic procedure under general anesthesia for resection of the tumor. A good perioperative course was achieved by the transfusion of ABO-identical and antihistocompatibility locus antigen-matched platelets, without causing any accidental bleeding.

Colon metastasis 20 years after the removal of ovarian cancer: Report of a case.

This report describes the case of a patient who had undergone surgery to resect bilateral ovarian tumors and then presented with colon metastasis 20 years later. A 69-year-old woman was admitted to the hospital for a clinical survey. She had been operated on for bilateral ovarian cancer in 1987 and was treated by postoperative adjuvant chemotherapy. The patient's follow-up showed no abnormality until 2006. Colonoscopy revealed an elevated irregular lesion in the cecum. A biopsy of the lesion showed a group V, moderately differentiated adenocarcinoma. A right hemicolectomy with a partial resection of the ileum and a lymphadenectomy was performed. Immunohistochemical staining during the pathological diagnosis showed the lesion to be colon metastasis from a serous papillary adenocarcinoma of the ovary. Immunohistochemical staining was positive for cytokeratin 7, carbohydrate antigen (CA)-125, and estrogen receptors, and negative for cytokeratin 20, carcinoembryonic antigen, and CA19-9. The use of immunohistochemistry demonstrated the tumor to be of ovarian origin.

Clinical significance of Smac/DIABLO expression in colorectal cancer.

Second mitochondria-derived activator of caspases/direct inhibitor of apoptosis-binding protein with low pI (Smac/DIABLO) is released by mitochondria in response to apoptotic stimuli and is thought to regulate apoptosis by antagonizing inhibitors of apoptosis proteins, which play an important role in sensitization of cancer cells to various therapeutic regimens. The expression of Smac/DIABLO has been demonstrated in various cancer cells, though little is known about its clinical significance with respect to colorectal cancer. The current study was designed to evaluate the relationship between prognosis and Smac/DIABLO expression by clinicopathological analysis of patients with colorectal cancer. Smac/DIABLO expression was evaluated using immunohistochemical staining in 121 consecutive patients with colorectal cancer and the relationship between Smac/DIABLO expression and clinicopathological factors was analyzed. Smac/DIABLO-positive expression was detected in 80 of the 121 patients (66%). The incidence of lymph node and distant metastasis in Smac/DIABLO-negative cancer was significantly higher than that in Smac/DIABLO-positive cancer (P=0.0004 and P=0.003, respectively). While univariate analysis showed that survival in patients with Smac/DIABLO-negative expression was significantly poorer than in Smac/DIABLO-positive cases (P<0.0001), Smac/DIABLO-negative expression was a prognostic indicator independent of Dukes' staging and lymph node metastasis by multivariate analysis. This study proposes that the decrease of Smac/DIABLO expression is an independent factor determining the poorer prognosis of patients with colorectal cancer.

Retrospective study of S-1 versus tegafur/uracil and oral leucovorin in patients with metastatic colorectal cancer.

UNLABELLED: THE AIM of this study was to compare the efficacy and toxicity of S-1 to an oral combination regimen of tegafur and uracil (UFT) with leucovorin (LV) in metastatic colorectal carcinoma (CRC) patients. PATIENTS AND METHODS: Fifty-two patients were treated with either S-1 (80 mg/m2/d), administered for 28 days every 42 days, or UFT (300 mg/m2/d) and LV (90 mg/d), administered for 28 days every 35 days. The clinical results were compared retrospectively. RESULTS: There were no statistically significant differences in overall response between the two patient groups. The overall response rate was 11.8% in the S-1 group, and 11.1% in the UFT/LV group. No statistically significant difference in-time- to progression (TTP) or survival time was observed between the treatments. The median survival time was 29 months with S-1 and 12 months with UFT/LV. CONCLUSION: The oral S-1 provided similar safety and efficacy, compared to UFT/LV for metastatic CRC.

Long-term remission of primary gastric T cell lymphoma associated with human T lymphotropic virus type 1: a report of two cases and review of the literature.

Two cases of primary gastric T-cell lymphoma associated with human T lymphotropic virus type 1 (HTLV-1) are presented. Case 1 was a 54-year-old man who had multiple ulcerating tumors in the lower corpus and gastric antrum. Case 2, a 60-year-old man, showed a large ulcerating tumor in the upper corpus. Both patients were positive for serum anti-HTLV-1 antibody and for the monoclonal integration of HTLV-1 proviral DNA in the tumor cells by Southern blot analysis. The patients were thus diagnosed as having primary gastric T-cell lymphoma associated with HTLV-1 of stage II(1). Case 1 underwent total gastrectomy followed by chemotherapy, while Case 2 was treated by chemotherapy and radiotherapy. Both patients have been in complete remission for more than 4 years (96 months in Case 1 and 50 months in Case 2) after the treatments. Although primary gastric T-cell lymphomas associated with HTLV-1 is characterized by an extremely poor prognosis, the present cases suggest that in the early stage, long-term survival can possibly be achieved with appropriate treatments.

[The efficacy and safety of docetaxel for elderly advanced breast cancer patients].

We studied the efficacy and safety of docetaxel (DOC) for elderly breast cancer patients. Between September 1997 and June 2003, five consecutive women with advanced breast cancers who were 75 years of age or older received DOC at a dose of 60 mg/m(2) every three weeks. No premedications to prevent hypersensitive reactions and fluid retention by DOC were given. The number of DOC dosages per case was 5-16 times (12 times the median) and the relative dose intensity (RDI) was 80-100% (95% of medians). Objective partial responses were observed in all patients. The median time to partial response was 21 days (range: 21-50 days). The median time to treatment failure was 12 months (range: 5-22 months). The grade and the frequency of major side effects were the following: leukocytopenia of grade 3 (80%), edema of grade 2-3 (40%), and alopecia of grade 2 (100%). It was concluded from these findings that DOC could be safely and effectively administered to elderly advanced breast cancer patients.

[A case of aged recurrent breast cancer with multiple lung metastases responding to examestane monotherapy].

An 85-year-old woman suffering from an angina attack was admitted to our hospital, and diagnosed with multiple lung metastases by CT scan. Because she was extremely aged with a long disease-free period of over 12 years, and without any life-threatening state despite multiple lung metastases, she received hormonal therapy. Examestane was considered one of the most-effective hormonal drugs for metastatic breast cancer. The efficacy of the treatment was definite: the multiple metastatic lesions showed a partial response after 5 months'treatment, and reached a complete response after 10 months'treatment. After 8 months in the complete response state, CT scan revealed progressive disease. Fortunately, the lung metastatic lesions were only slowly progressive, and she has no symptoms now. There was no side effect except for complication of subdural hematoma. Examestane is considered highly effective for metastatic breast cancer and well tolerated by an aged patient like this case.

Role of femorofemoral crossover bypass grafting for unilateral iliac atherosclerotic disease: a comparative evaluation with anatomic bypass.

PURPOSE: To assess the role of femorofemoral or iliofemoral crossover bypass grafting, the early and late results of crossover bypasses were reviewed and compared with those of anatomic bypasses. METHODS: The clinical records of 164 patients with arteriosclerosis obliterans who underwent 99 crossover bypasses and 65 anatomic ones from 1982 to 2002 were retrospectively evaluated. The early and late results including operative mortality and morbidity, graft patency rate, limb salvage rate, and survival rate of the patients as well as backgrounds of the patients were compared between the two kinds of bypass procedures. In addition, perioperative factors including bypass procedures affecting graft patency were evaluated by a multivariate analysis. RESULTS: The percentage of high-risk patients was higher in the crossover bypass group than in the anatomic bypass group. The operative mortality and morbidity were similar between both bypass groups. The primary and secondary patency rates of crossover bypass grafts (93% and 97%, 83% and 92%, and 65% and 63% at 2, 5, and 10 years, respectively) were lower than those of anatomic ones (95% and 98%, 93% and 98%, and 90% and 98% at 2, 5, and 10 years, respectively). The late survival of the patients in the crossover bypass group was significantly lower than that in the anatomic bypass group. A multivariate analysis revealed the operative method, namely the crossover bypass, to be the only significant risk factor of late graft failure. CONCLUSION: A crossover bypass was thus determined to be an acceptable procedure only in high-risk patients with a limited life expectancy.

A traumatic pseudoaneurysm of the dorsalis pedis artery: report of a case.

A 63-year old woman underwent a resection of a pseudoaneurysm in the dorsalis pedis artery. The aneurysm was suggested to have formed because of a bruise on the dorsal aspect of the foot 5 years previously. This is a rare case of a traumatic aneurysm in the peripheral artery.

Aortocaval fistula complicated with bacteremia due to Escherichia coli: report of a case.

We herein report a case of aortocaval fistula complicated with bacteremia due to Escherichia coli in a 78-year-old man who underwent an emergency operation. A surgical resection of the abdominal aortic aneurysm with a closure of the fistula, and reconstruction with an expanded polytetrafluoroethylene bifurcated graft and wrapping with an omental flap, were performed followed by a 9-week continuous administration of antibiotics. Thereafter, antifungal agents were administered and the results were good. Both an early diagnosis and prompt surgery are important for such patients, and long-term administration of antibacterial agents is also necessary.