The Utility of Diagnostic Laparoscopic Biopsy for Mesenteric and Retroperitoneal Lymph Nodes.

BACKGROUND Ultrasound (US) or computed tomography (CT)-guided biopsy of intra-abdominal lymph nodes is minimally invasive; however, percutaneous procedures are often difficult to perform because of the location and size of the lymph nodes. In many cases, this approach may result in insufficient specimens necessary to evaluate histopathology. In such cases, laparoscopic biopsy is useful to obtain adequate specimens, regardless of the location and size of the lymph nodes. Additionally, laparoscopic biopsy is an approach that can avoid the possible complications associated with a laparotomy. CASE REPORT Between 2013 and 2016, a series of 11 patients underwent laparoscopic biopsy of mesenteric and retroperitoneal lymph nodes. All patients received a definitive histopathological diagnosis via laparoscopic biopsy. The median postoperative hospital stay was four days (range 3-13 days), and all patients were able to resume oral intake on postoperative day 1. No case was converted to laparotomy, and no major perioperative complication occurred, except for wound infection in one patient. CONCLUSIONS Diagnostic laparoscopic biopsy for mesenteric and retroperitoneal lymph nodes is safe and reliable.

The Benefits of a Wound Protector in Preventing Incisional Surgical Site Infection in Elective Open Digestive Surgery: A Large-Scale Cohort Study.

BACKGROUND: The objective of this study was to evaluate the benefits of wound protectors (WPs) in preventing incisional surgical site infection (I-SSI) in open elective digestive surgery using data from a large-scale, multi-institutional cohort study. METHODS: Patients who had elective digestive surgery for malignant neoplasms between November 2009 and February 2011 were included. The protective value of WPs against I-SSI was evaluated. RESULTS: A total of 3201 patients were analyzed. A WP was used in 1022 patients (32%). The incident rate of I-SSI (not including organ/space SSI) was 9%. In the univariate and the multivariate analyses for perioperative risk factors for I-SSI, the use of WP was an independent favorable factor that reduced the incidence of I-SSI (odds ratio 0.73, 95% confidence interval 0.55-0.98. P = 0.038). The subgroup forest plot analyses revealed that WP reduced the risk of I-SSI only in patients aged 74 years or younger, males, non-obese patients (body mass index <25 kg/m2), patients with an American Society of Anesthesiologists score of 1/2, patients with a previous history of laparotomy, non-smokers, and patients who underwent colon and rectum operations. In patients who underwent colorectal surgery, the postoperative hospital stay was significantly shorter in patients with WP than those without WP (median 13 vs. 15 days, P = 0.040). In terms of the depth of SSI, WP only prevented superficial I-SSI and did not reduce the incidence of deep I-SSI. CONCLUSIONS: WP is a useful device for preventing superficial I-SSI in open elective digestive surgery. TRIAL REGISTRATION NUMBER: UMIN000004723.

Angiosarcoma arising in the non-operated, sclerosing breast after primary irradiation, surviving 6 years post-resection: A case report and review of the Japanese literature.

INTRODUCTION: Angiosarcoma consists only 0.04% of all breast malignancies and has a poor prognosis. This is the first reported case of an angiosarcoma arising in the non-operated breast after primary irradiation for occult breast cancer. The patient underwent mastectomy, surviving disease free for 6 years. PRESENTATION OF CASE: A 73-year-old woman with a past history of irradiation of the non-operated left breast complained of skin thickening and crust formation on the left nipple 8 years post-irradiation. Considering the clinical history and radiological studies, recurrent cancer was suspected and biopsy was performed. However, no proof of malignancy was obtained. As clinical symptoms continued to advance, informed consent was obtained and mastectomy was performed. Histological examination of the surgical specimen revealed angiosarcoma. DISCUSSION: In this case, angiosarcoma occurred after radiation on a non-operated breast. Preoperative diagnosis was not achieved even with two cytology specimen and one biopsy. Each showed only fibrosis and inflammatory changes. The background breast tissue inflammation should have been caused by radiation. Marked fibrosis and the rather small number of sarcoma cells in the breast tumor in this case may be why bioptic diagnosis was difficult. Kaplan-Meier analysis of 60 Japanese breast angiosarcoma patients showed significantly better prognosis in patients with a tumor 2cm or smaller. CONCLUSION: Angiosarcoma may occur in the non-operated breast, post irradiation. The potential difficulties of diagnosing angiosarcoma against background fibrosis should be kept in mind. Initial radical surgery currently represents the only effective treatment for improving survival in these patients.

Gastric carcinoma with an invasive micropapillary carcinoma component showing HER2 gene amplification and CD10 expression: a case report and review of the literature.

An 81-year-old man was referred to our hospital because gastric cancer was detected on screening esophagogastroduodenoscopy. Surgical resection of the tumor was performed. It was 25 × 20 mm in size and swollen lymph nodes were present nearby. Lymphadenectomy was also performed. Histopathologically, the tumor reached the proper muscle layer via venous invasion. There were three components that constituted the tumor, that is, 40% of mass was invasive micropapillary carcinoma (IMPC), 40% was papillary adenocarcinoma and 20% tubular adenocarcinoma. Vascular invasion was prominent. Immunohistochemistry revealed that the tumor showed an entirely intestinal mucin phenotype, being positive only for CD10 and negative for MUC2, MUC5AC, and MUC6. HER2 staining score ranged from 2+ to 3+, depending on the components described above. HER2 gene amplification was present in all the components according to dual-color in situ hybridization. The metastatic lymph nodes were similar to the primary site in morphology and immunohistochemistry, but HER2 amplification was higher in the lymph nodes. The IMPC component with HER2 amplification is rarely seen and its positivity for CD10 is an unexpected finding for gastric IMPC. Hence, this is a highly unusual case judging by the literature; further studies are needed to clarify the nature of gastric IMPC.

Expression of short-chain fatty acid receptor GPR41 in the human colon.

Short-chain fatty acids (SCFAs), including acetate, propionate and butyrate, are the most commonly found anions found in the monogastric mammalian large intestine, and are known to have a variety of physiological and pathophysiological effects on the gastrointestinal tract. We investigated the protein and mRNA expression levels of GPR41, a possible G protein coupled receptor for SCFA, using Western blot analysis and reverse transcriptase-polymerase chain reaction. We found that GPR41 protein and mRNA are expressed in human colonic mucosa. Immunohistochemistry for GPR41 showed that mucosal GPR41 protein is localized in cytoplasm of enterocytes and enteroendocrine cells. Moreover, GPR41-immunoreactive endocrine cells contained peptide YY but not serotonin or GPR43. The cellular population of GPR41 (0.01 +/- 0.01 cells/crypt) was much smaller than that of GPR43 (0.33 +/- 0.01 cells/crypt) in the human colon. However, the potency order of SCFA-induced phasic contraction of colonic smooth muscle that we previously reported is consistent with GPR41 (propionate >or= butyrate > acetate) but not GPR43 (propionate = butyrate = acetate). Therefore, the present study suggests that GPR41 expressed in human colonic mucosa may function as a sensor for luminal SCFAs.

Efficacy of preoperative dexamethasone in patients with laparoscopic cholecystectomy: a prospective randomized double-blind study.

BACKGROUND/PURPOSE: Dexamethasone has been reported to reduce postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy (LC). However, its effect on other surgical outcomes such as pain and fatigue have been unclear. The purpose of this clinical study was to evaluate the efficacy of preoperative dexamethasone in ameliorating postoperative symptoms after LC. METHODS: In this prospective, double-blind, placebo-controlled study, 80 patients scheduled for LC were analyzed after randomization to intravenous dexamethasone (8 mg) or placebo. All patients underwent standardized procedures for general anesthesia and surgery, and were recommended to remain in hospital for 3 postoperative days. Episodes of PONV, and pain and fatigue scores on a visual analogue scale (VAS) were recorded. Analgesic and antiemetic requirements were also recorded. RESULTS: There were no apparent side effects of the study drug. Seven patients (18%) in the dexamethasone group reported nausea, compared with 16 (40%) in the placebo group (p = 0.026). One patient (3%) in the dexamethasone group and 7 (18%) in the placebo group reported vomiting (p = 0.025). Dexamethasone significantly reduced the postoperative VAS pain score (p = 0.030) and VAS fatigue score (p = 0.023). The mean number of patients requiring diclofenac sodium 50 mg was 0.9 +/- 1.3 in the dexamethasone group and 2.2 +/- 2.5 in the placebo group (p = 0.002). CONCLUSIONS: The regimen we employed is safe and without apparent side effects. These results suggest that preoperative dexamethasone (8 mg) significantly reduces the incidence of PONV, pain, and fatigue after LC.

Side-to-end anastomosis in a colostomy for acute malignant large-bowel obstruction: side-to-end anastomosis with a colostomy (STEC procedure).

This report describes the use of side-to-end anastomosis in a colostomy for an acute malignant large-bowel obstruction. A 59-year-old man presented with a colonic obstruction due to advanced descending colon cancer. The preoperative imaging studies revealed a complete obstruction of the descending colon at the site of the splenic flexure, a remarkably dilated transverse colon, and no other metastatic lesions. Side-to-end anastomosis was performed with the colostomy because of the high comorbidity associated with such cases. When the patient's general condition improved, a stoma closure was performed under local anesthesia. In conclusion, a side-to-end anastomosis with a colostomy (STEC procedure) was found to be a simple, useful, and cost-effective technique for an acute malignant large-bowel obstruction, particularly in a high-risk patient.

Secretory effects of a luminal bitter tastant and expressions of bitter taste receptors, T2Rs, in the human and rat large intestine.

Taste transduction molecules, such as Galpha(gust), and taste receptor families for bitter [taste receptor type 2 (T2R)], sweet, and umami, have previously been identified in taste buds and the gastrointestinal (GI) tract; however, their physiological functions in GI tissues are still unclear. Here, we investigated the physiological function and expression of T2R in human and rat large intestine using various physiological and molecular biological techniques. To study the physiological function of T2R, the effect of a bitter compound, 6-n-propyl-2-thiouracil (6-PTU), on transepithelial ion transport was investigated using the Ussing chamber technique. In mucosal-submucosal preparations, mucosal 6-PTU evoked Cl(-) and HCO(3)(-) secretions in a concentration-dependent manner. In rat middle colon, levels of 6-PTU-evoked anion secretion were higher than in distal colon, but there was no such difference in human large intestine. The response to 6-PTU was greatly reduced by piroxicam, but not by tetrodotoxin. Additionally, prostaglandin E(2) concentration-dependently potentiated the response to 6-PTU. Transcripts of multiple T2Rs (putative 6-PTU receptors) were detected in both human and rat colonic mucosa by RT-PCR. In conclusion, these results suggest that the T2R ligand, 6-PTU, evokes anion secretion, and such response is regulated by prostaglandins. This luminal bitter sensing mechanism may be important for host defense in the GI tract.

A case of anaplastic carcinoma of the pancreas producing granulocyte-colony stimulating factor.

We report a case of anaplastic carcinoma of the pancreas with production of granulocyte-colony stimulating factor (G-CSF) in a 59-year-old male. He was referred to our hospital with a chief complaint of epigastralgia and suffered from leukocytosis. Differential diagnosis included pancreatic tumors and submucosal tumor of the stomach, but definite preoperative diagnosis could not be made. He underwent distal pancreactomy, total gastrectomy with Roux-en-Y reconstruction and splenectomy. He recovered uneventfully postoperatively and was discharged from hospital on the 14th postoperative day. Histological examination showed anaplastic carcinoma of the pancreas. Since the peripheral leukocyte count was sharply decreased after the operation, we suspected the tumor would be producing G-CSF. Then immunohistochemistry showed a positive stain in the tumor. Therefore, we diagnosed the tumor as anaplastic carcinoma of the pancreas producing G-CSF. Three months after the resection, local recurrence was detected by abdominal computed tomography. The patient died of hemorrhagic shock due to tumor invasion of the intestine 8 months after the operation.