A Japanese infant presenting with hypocalcemic seizures resulting from hypovitaminosis D induced by non-celiac gluten sensitivity.

Vitamin D deficiency is a major cause of hypocalcemic seizures in infants. Chronic enteropathy can cause both malnutrition and vitamin deficiency disorders, such as celiac disease, in Western Caucasians. However, gluten-related disorders are considered uncommon in most Asian countries, and there have been no reports of any infant being diagnosed with a gluten-related disorder in Japan. Here, we describe a case where a Japanese infant, with non-celiac gluten sensitivity, presented with hypocalcemic seizures resulting from a vitamin D deficiency. In this case, an eight-month-old boy had an afebrile seizure, and blood tests revealed both hypocalcemia and prolonged prothrombin time resulting in his transfer to our hospital. The presence of fatty stools and evidence of multiple vitamin deficiencies indicated some form of fat malabsorption. His laboratory and histological findings showed enteropathy, and he was thus diagnosed with non-celiac gluten sensitivity. Therefore, he was treated with a gluten-free diet supplemented with vitamins. This case suggests that infants with a vitamin D deficiency caused by celiac disease or non-celiac gluten sensitivity should be carefully monitored when they are given oral supplements of vitamin D, to prevent any adverse side-effects associated with the varied roles of vitamin D in the immune response.

Label-free detection of human enteric nerve system using Raman spectroscopy: A pilot study for diagnosis of Hirschsprung disease.

BACKGROUND: Hirschsprung disease (HSCR) is characterized by the absence of an enteric nerve system (ENS). To remove aganglionosis, bowel reconstruction is only a curative treatment. It is mandatory to identify the extent of aganglionosis during surgery. Raman spectroscopy is a nondestructive chemical analysis technique that provides detailed information regarding molecular vibrations. The purpose of this study is to detect the ENS using Raman spectroscopy in the human intestine for diagnosis of HSCR. METHODS: The Raman spectra of each layer of the gastrointestinal wall were collected from surgical specimens of the human rectum. Based on collected spectral data, principal component analysis was performed to determine the ENS. Subsequently, the Raman spectra of HSCR sections were analyzed. RESULTS: Molecular structures of the gastrointestinal wall were characterized by Raman spectroscopy. Raman spectroscopy could discriminate between ganglion and muscle layers, and the spectra of the border between muscle layers in the aganglionosis were collagen-associated peaks. Either absence on presence of ENS was also confirmed in HSCR material. CONCLUSIONS: Label-free detection of the ENS was successfully demonstrated using Raman spectroscopy. Since this is a preliminary study, the strategy which may contribute to differentiate between ganglionic and aganglionic segments using noninvasive techniques in HSCR should be evaluated by prospective studies in near future.

Laparoscopic fundoplication for a case of esophageal hiatal hernia after gastroschisis repair.

BACKGROUND: Esophageal hiatal hernia and gastroesophageal reflux have been recognized as inevitable complications after the definitive gastroschisis operation. Patients with refractory gastroesophageal reflux require anti-reflux surgery; however, the surgical adhesions may complicate subsequent surgical therapy, especially in the cases treated by staged repair. CASE PRESENTATION: A male infant who showed a severe gastroesophageal reflux due to hiatal hernia after staged abdominal fascial closure of gastroschisis. In spite of continuous conservative management, frequent vomiting and hematemesis had become progressively worse at the age of 8 months. Laparoscopic Nissen fundoplication was attempted and completed with no adverse events. CONCLUSIONS: Laparoscopic fundoplication may be applied, as a first-line approach, for the treatment of gastroesophageal reflux in this difficult group of patients, after the repair of congenital abdominal wall defect.

A case of advanced gastric cancer achieved a pathological complete response by chemotherapy.

BACKGROUND: Although chemotherapy is the first recommended treatment of unresectable gastric cancer, a pathological complete response is a rare event. CASE PRESENTATION: A 58-year-old male was diagnosed as gastric cancer with a bulky tumor, lymphadenopathy, and suspicious peritoneal dissemination. The patient underwent chemotherapy with S-1 and cisplatin. After three courses of chemotherapy, a computed tomography showed dramatic improvements in gastric wall thickening, shrinkage of lymphadenopathy, and disappearance of disseminated peritoneal lesion. The patient underwent potentially curative resection by total gastrectomy with D2 lymph node dissection. Histological examination revealed the absence of malignant cells not only in the resected specimen but also in the harvested lymph nodes. At present, more than 7 years after the initial surgery, the patient is still alive without any recurrence. CONCLUSIONS: We obtained a pathological complete response by chemotherapy with S-1 and cisplatin for advanced gastric cancer. Although a pathological complete response is a rare event, it would be associated with the long-term survival of patients with advanced gastric cancer.

Serosal and muscular layers incision technique in laparoscopic surgery for gastric gastrointestinal stromal tumors.

INTRODUCTION: To minimize the resection of stomach tissue, especially for lesions close to the esophagogastric junction or pyloric ring, we developed laparoscopic wedge resection with the serosal and muscular layers incision technique (SAMIT) for gastric gastrointestinal stromal tumors. MATERIALS AND SURGICAL TECHNIQUE: SAMIT involves resection of the mucosal and submucosal layers and then an incision in serosal and muscular layers around the tumor. SAMIT is simple and does not require special devices. The data of 13 patients who underwent laparoscopic wedge resection with SAMIT for primary gastric gastrointestinal stromal tumors were reviewed. No intraoperative complications were observed, and postoperative stenosis occurred in only one case of a middle stomach lesion. Adequate oncological resection was performed in all cases. DISCUSSION: Laparoscopic wedge resection with SAMIT is technically and oncologically safe. It is useful for treating gastric gastrointestinal stromal tumors, including those close to the esophagogastric junction or pyloric ring.

Comparing incidence of enterocolitis after laparoscopic and open low anterior resection for stage II/III rectal cancer.

INTRODUCTION: We recently observed an increased incidence of severe enterocolitis following laparoscopic low anterior resection (LAR) in some patients with stage II/III rectal cancer. This study aimed to examine the influence of laparoscopic LAR on postoperative enterocolitis compared with open LAR for Stage II/III rectal cancer. METHODS: From April 2002 to March 2012, we evaluated 65 patients with stage II/III cancer of the upper or lower rectum who underwent LAR. Among these, 27 patients underwent open LAR and 38 underwent laparoscopic LAR. First, we compared short-term outcomes between the two groups. Next, we evaluated the incidence of postoperative enterocolitis in the laparoscopic LAR group. The clinicopathological factors were examined by univariate and odds ratio (OR) analysis. RESULTS: Univariate analysis revealed significant differences in the occupancy rate, tumor location, depth of tumor invasion, operative time, amount of intraoperative blood loss, and postoperative enterocolitis between the laparoscopic and open groups. Postoperative enterocolitis developed in 6 of 38 patients (15.8%) in the laparoscopic group and in no patient in the open group. The occurrence of postoperative enterocolitis was significantly associated with BMI (≥28 kg/m(2) ), operative time, and wound infection in the laparoscopic LAR group (OR: 0.11, 95% confidence interval: 0.044-0.280, P < 0.05; OR: 1.40, 95% confidence interval: 1.068-1.835, P < 0.05; and OR: 15.0, 95% confidence interval, 1.752-128.310, P < 0.05, respectively). CONCLUSION: Postoperative enterocolitis occurred more frequently after laparoscopic LAR than after open LAR in patients with stage II/III rectal cancer. Clinical management in the perioperative period of laparoscopic LAR is necessary to prevent postoperative enterocolitis in obese patients and those with a prolonged operative time.

A comparison of laparoscopic and open surgery following pre-operative chemoradiation therapy for locally advanced lower rectal cancer.

OBJECTIVE: Although pre-operative chemoradiation therapy for advanced lower rectal cancer is a controversial treatment modality, it is increasingly used in combination with surgery. Few studies have considered the combination of chemoradiation therapy followed by laparoscopic surgery for locally advanced lower rectal cancer; therefore, this study aimed to assess the usefulness of this therapeutic combination. METHODS: We retrospectively reviewed the medical records of patients with locally advanced lower rectal cancer treated by pre-operative chemoradiation therapy and surgery from February 2002 to November 2012 at Oita University. We divided patients into an open surgery group and a laparoscopic surgery group and evaluated various parameters by univariate and multivariate analyses. RESULTS: In total, 33 patients were enrolled (open surgery group, n = 14; laparoscopic surgery group, n = 19). Univariate analysis revealed that compared with the open surgery group, operative time was significantly longer, whereas intra--operative blood loss and intra-operative blood transfusion requirements were significantly less in the laparoscopic surgery group. There were no significant differences in post-operative complication and recurrence rates between the two groups. According to multivariate analysis, operative time and intra-operative blood loss were significant predictors of outcome in the laparoscopic surgery group. CONCLUSIONS: This study suggests that laparoscopic surgery after chemoradiation therapy for locally advanced lower rectal cancer is a safe procedure. Further prospective investigation of the long-term oncological outcomes of laparoscopic surgery after chemoradiation therapy for locally advanced lower rectal cancer is required to confirm the advantages of laparoscopic surgery over open surgery.

Using an indwelled test tube as a good "navigator" during enterostomy closure.

Surgeons often have difficulty in identifying a suitable incision line to enter the peritoneal cavity for stoma mobilization during enterostomy closure. A mini-size test tube that is preoperatively placed into the stoma can act as an efficient guide in finding a free area to enter the peritoneal cavity, by supplying efficient counter traction and a palpable marker of the intestinal wall.

Suppression of tumor growth in human gastric cancer with HER2 overexpression by an anti-HER2 antibody in a murine model.

New modalities are necessary for the treatment of patients with unresectable gastric cancer. The aim of this study was to investigate whether or not anti-HER2 antibody could suppress the growth of human gastric cancer cells with HER2 overexpression in vitro and in vivo. Four human gastric cancer cell lines, NCI-N87, MKN-45P, Kato-III, and MKN-1, were used in this study. The suppression of cell proliferation in vitro and of subcutaneous tumor growth in a nude mouse model after treatment with trastuzumab was examined. The expression of HER2 protein was investigated by Western blot analysis. The effect of trastuzumab on the survival rate of nude mice with peritoneal dissemination was examined. Trastuzumab significantly reduced proliferative activity in NCI-N87, a HER2-overexpressing human gastric cancer cell line, in vitro. In the nude mouse model with transplanted subcutaneous tumor, trastuzumab significantly suppressed the tumor growth of NCI-N87 cells, and then HER2 expression was reduced. Trastuzumab improved the survival rate of mice with peritoneal dissemination of MKN-45P cells. Trastuzumab therapy is a potential candidate for a novel treatment of HER2-overexpressing gastric cancer.