Small intestinal perforation due to metastasis of breast carcinoma: report of a case.

A 79-year-old female patient underwent breast-conservation surgery following a diagnosis of right breast cancer in July 2007. In November 2008, the patient presented at our hospital with acute onset of lower abdominal pain. She was diagnosed with panperitonitis due to gastrointestinal perforation, and underwent an emergency operation. At the time of the operation, one site of free perforation was found in the small intestine, and a 2-3-cm nodule was found in the 50-cm anal side from the site of this perforation. Multiple metastases to the para-aortic lymph nodes and mesenteric lymph nodes were also found. The patient recovered without complications and was discharged from the hospital, but 3 months after surgery she succumbed due to multiple liver metastases. It is important to identify metastatic intestinal tumors in patients who have breast cancer.

A case of long partial response to combination therapy of bevacizumab and capecitabine for liver metastases of rectal cancer.

A 69-year-old female visited our department with a diagnosis of rectosigmoid cancer and multiple hepatic metastases (stage IV). Abdominal CT revealed multiple metastatic lesions in the bilateral lobes of the liver. The primary lesion was considered to be resectable, and high anterior resection of the rectum was performed. After the operation, 6 courses of therapy with bevacizumab (BV) and modified FOLFOX6 were performed. CT showed a partial response, and tumor marker levels became normal. After a total of 11 courses of this therapy, grade 3 peripheral neuropathy developed, and the therapy was changed to BV and capecitabine (Cape). After 6 courses of this therapy, CT showed the maintenance of partial response, and tumor marker levels were also within the normal range. BV and Cape therapy may be useful not only for reducing peripheral neuropathy, but also as a maintenance therapy in patients requiring the suspension of oxaliplatin administration due to peripheral neuropathy.

Fixation of the round ligament to the peritoneum and wrapping of the cut surface of the liver for prevention of early delayed gastric emptying after hepatic lateral segmentectomy.

PURPOSE: Left-sided hepatectomy occasionally leads to early delayed gastric emptying (EDGE). We developed a new fixation procedure of the round ligament to the peritoneum to prevent EDGE after hepatic lateral segmentectomy and evaluated its efficacy. METHODS: We retrospectively studied 42 patients who underwent hepatic lateral segmentectomy. They were divided into two groups: a fixation group (N = 15) and a nonfixation group (N = 27). The round ligament of the liver was divided at the umbilicus and detached from the abdominal wall from the umbilicus to the liver. The cut surface of the liver was wrapped by the round ligament, and the distal part of the round ligament was then fixated to the peritoneum. RESULTS: EDGE was found to be 0% in the fixation group versus 15% in the nonfixation group. CONCLUSIONS: Fixation of the round ligament to the peritoneum is a useful technique to prevent EDGE after hepatic lateral segmentectomy.

Implantation of a Denver shunt by left subclavian approach for preventing kinking.

Ascites often contributes to patient morbidity and discomfort. Implantation of a Denver peritoneovenous shunt is one of the treatments for refractory ascites. However, the dysfunction of the shunt is frequently observed and requires further improvement. Here, the present paper reported the improved implantation technique for the Denver peritoneovenous shunt. All the procedures were performed in the operating suite under general anesthesia. In all patients, the shunts were percutaneously placed via the left subclavian vein approach under digital fluoroscopic guide along with ultrasound. Fourteen shunts were implanted in 14 patients with hepatic failure-related ascites. The shunt was successfully positioned in all patients in an average time of 45 min without the kinking. No complications directly related to the procedure occurred. The Denver peritoneovenous shunt is useful in resolution of refractory ascites, as it reduces symptoms, and allows effective palliation. Implantation of the Denver peritoneovenous shunt via left subclavian vein approach is a relatively easy, rapid, and secure procedure that prevents kinking.

Long-term outcome of laparoscopic deroofing for symptomatic nonparasitic liver cysts.

BACKGROUND/AIMS: The use of the laparoscopic procedure for managing symptomatic nonparasitic liver cysts has been documented to be feasible and safe in the short term; however, the long-term outcomes of the procedure have not been well demonstrated. This study was initiated to review the long-term outcomes of this procedure. METHODOLOGY: Preoperatively, diagnosis was established by ultrasonography (US), computed tomography (CT) scan, and endoscopic retrograde cholangiography or magnetic resonance cholangiographic photograph. The long-term outcomes in 8 patients with symptomatic nonparasitic simple liver cysts treated by laparoscopic deroofing are presented. All patients were followed up, and morphologic evaluation was performed with repeated abdominal US and CT. RESULTS: All operations could be finished laparoscopically without converting to open laparotomy. Intra- and postoperative complications were not detected. The mean follow-up duration in all cases was 122.5 months (range: 79-149 months). Two patients exhibited morphologic recurrence within 6 months after surgery and required a second treatment. CONCLUSIONS: From the observation of long-term follow-up, we concluded that laparoscopic deroofing is a useful method for treating symptomatic nonparasitic liver cysts.

Laparoscopic excision for an enlarged ciliated hepatic foregut cyst as a minimally invasive procedure.

Ciliated hepatic foregut cyst (CHFC) is a very rare cystic lesion of the liver. Although CHFC has traditionally been considered to lack malignant potential, recent reports have shown the malignant transformation of this lesion into squamous-cell carcinoma. It is difficult to differentiate CHFC from malignant tumor, and it is important to consider in aspiration cytology for the evaluation of possible neoplastic disease. In this paper, we describe the case of a 57-year-old female who underwent a laparoscopic excision of an enlarged CHFC that was diagnosed by fine-needle aspiration cytology. Laparoscopic excision may be adopted as a minimally invasive surgical procedure for CHFC.

Mediastinoscopy-assisted esophagectomy is useful technique for poor surgical-risk patients with thoracic esophageal cancer.

Elderly and poor surgical-risk patients with esophageal cancer experience several complications and often cannot undergo standard transthoracic esophagectomy. Mediastinoscopy-assisted esophagectomy (MAE) recently has been applied in patients with thoracic esophageal cancer. We herein report 2 poor surgical-risk patients of lower thoracic esophageal cancer treated with MAE. Patient 1 was a 60-year-old man with respiratory impairment due to pulmonary tuberculosis whereas patient 2 was an 80-year-old man with poor performance status and nutritional condition. In these patients, MAE was performed because standard esophagectomy by thoracotomy is too difficult to perform. We performed MAE using the mediastinoscope approaches via both the neck and hiatus. An approach via the hiatus is useful for mobilization of lower thoracic esophagus and via the neck is useful for direct visualization of recurrent nerve. These patients were successfully treated without complications. MAE enables the mobilization of the thoracic esophagus under the direct visualization in the mediastinum, and it may be considered to be safe and useful technique for elderly and poor surgical-risk patients.

Development of pyrrole-imidazole polyamide for specific regulation of human aurora kinase-A and -B gene expression.

Pyrrole-imidazole polyamide (PIP) is a nuclease-resistant novel compound that inhibits gene expression through binding to the minor groove of DNA. Human aurora kinase-A (AURKA) and -B (AURKB) are important regulators in mitosis during the cell cycle. In this study, two specific PIPs (PIP-A and PIP-B) targeting AURKA and AURKB promoter regions were designed and synthesized, and their biological effects were investigated by several in vitro assays. PIP-A and PIP-B significantly inhibited the promoter activities, mRNA expression, and protein levels of AURKA and AURKB, respectively, in a concentration-dependent manner. Moreover, 1:1 combination treatment with both PIPs demonstrated prominent antiproliferative synergy (CI value [ED(50)] = 0.256) to HeLa cells as a result of inducing apoptosis-mediated severe catastrophe of cell-cycle progression. The novel synthesized PIP-A and PIP-B are potent and specific gene-silencing agents for AURKA and AURKB.

A case of asymptomatic intraductal papillary neoplasm of the bile duct without hepatolithiasis.

A 65-year-old woman was found to have dilatation of the intrahepatic bile duct in the right anterior segment during a general health. Laboratory data were within normal ranges and no solid mass was detected in her abdominal computer tomography (CT) or nuclear magnetic resonance imaging (MRI). However, endoscopic retrograde cholangiopancreatography (ERCP) demonstrated an obstruction of the right bile duct. Intraoperative cholangiography showed stenosis of the intrahepatic bile duct in the anterior inferior segment (B5) and narrowness of the intrahepatic bile duct in the anterior superior segment (B8), so that we strongly suspected intrahepatic cholangiocarcinoma (ICC). Histologically, surgically resected liver specimens, without tumor mass by macroscopic observation, showed intraductal papillary proliferation with fibrovascular cores and intraductal spreading of carcinoma in situ throughout a considerable area, especially in bile ductules around the peripheral small portal area. Furthermore, the immunohistochemical profile of the tumor (MUC5AC+/CK7+) was compatible with an intraductal papillary neoplasm of the bile duct (IPN-B). Consequently, this case was diagnosed as IPN-B with spreading CIS, stage I (pT1, pN0, P0, H1, M0). We report a case of IPN-B with interesting histopathological findings and emphasize that cholangiography is especially helpful for the diagnosis of bile duct dilatation due to infiltration of carcinoma cells.

Open abdomen management after massive bowel resection for superior mesenteric arterial occlusion.

PURPOSE: Massive bowel resection is often performed for superior mesenteric arterial (SMA) occlusion, resulting in short bowel syndrome. We conducted this study to evaluate the effectiveness of open abdomen management to monitor the blood flow of the remnant bowel and anastomoses. METHODS: We treated five of seven patients with SMA occlusion by open abdomen management, with or without mesh, using a zipper, which we opened daily to monitor the blood flow around the anastomotic site. RESULTS: None of the five patients treated by open abdomen management required re-resection of the remnant bowel and they were all discharged from hospital in a stable condition. CONCLUSION: Open abdomen management proved extremely useful for monitoring blood flow to the anastomotic site and for allowing complete drainage into the abdominal space. Using this method would assist in leaving as much remnant bowel as possible after resection for SMA occlusion.

A long-surviving patient with unresectable advanced gastric cancer responding to S-1 after receiving improved gastrojejunostomy.

Conventional gastrojejunostomy has been employed for unresectable advanced gastric cancer with pyloric stenosis; however, it is often not fully effective. We report a patient with unresectable gastric cancer who was effectively treated with an anticancer drug, S-1, after receiving an improved gastrojejunostomy. The patient was a 55-year-old woman who was referred to our hospital for epigastric pain. Upper gastrointestinal endoscopy showed a Borrmann III tumor in the antrum of the stomach, and gastric roentgenography showed pyloric stenosis. Preoperative findings were T3N2H0P0, stage III b. At operation, the tumor was found to have invaded the duodenum and the head of the pancreas, and disseminated nodules were found in the mesenterium of the small intestine, the left diaphragm, and the round ligament of the liver. A curative operation was impossible for the advanced gastric cancer. Therefore, an improved gastrojejunostomy was performed to allow oral intake. Oral intake started 7 days after the operation, and she left our hospital 20 days after the operation. She started treatment with 80 mg/day of S-1, given orally, for 28 days, followed by 14 days' rest, as 1 course. During 16 courses of the treatment, she maintained a performance status of 0 to 1 and maintained quality of life. However, she died because of pelvic dissemination and genital bleeding (caused by tumor invasion into the uterus) 2 years and 4 months after the surgery. This case suggested that the improved gastrojejunostomy was a useful method for treating unresectable gastric cancer, allowing the possibility of oral intake, and the use of S-1.

Decreased production of interleukin-12 and type 2 immune responses are marked in cachectic patients with colorectal and gastric cancer.

Balance of the two types of T helper cells is one of the most important factors for regulation of the immune system. This study examines the production of interleukin (IL)-4, -6, -10, -12, and interferon-gamma by peripheral blood mononuclear cells stimulated with phytohemagglutinin or Staphylococcus aureus. Sixty-one patients, including 25 with gastric and 39 with colorectal cancer, and 39 normal volunteers were entered. The production of IL-12 decreased significantly with advancing disease and was lowest in the patients with distant metastases and cachexia. Compared with normal donors, the production of interferon-gamma decreased in all categories of patients, with no difference among patient groups. Levels of Th2 cytokines, such as IL-4, IL-6, and IL-10, also showed no difference among patient groups. However, production of all these cytokines had increased by 2.5 months after sequential testing in the same cachectic patients. The authors' findings indicate that the induction of Th1 cells seems to be suppressed at a relatively early stage of disease, whereas that of Th2 cells seems to increase in the terminal stage.

Immunomodulatory effects of low dose cis-Diaminedichloroplatinum (cisplatin) combined with UFT and PSK in patients with advanced colorectal cancer.

It is well known that cell-mediated immunity is suppressed in patients with neoplastic diseases. We have reported that soluble receptors for interleukin-2 (sIL-2R) and tumor necrosis factor (sTNF-R1) are elevated in the serum of patients with advanced colorectal cancer. The presence of these soluble receptors and immunosuppressive cytokines, including interleukin-10 (IL-10), might be important in the mechanisms of immunosuppression. cis-Diaminedichloroplatinum (cisplatin) has been reported to immunomodulate, especially when used in low dose in combination with 5-Fluorouracil (5-FU). In this study, cisplatin and UFT, a form of uracil and tegafur which is a prodrug of 5-FU, were administered with immunomodulator Polysaccharide K (PSK) to ten patients with colorectal cancer, who showed distant metastasis in the liver or lung, and the serum levels of sIL-2R and sTNF-R1 and the production of gamma-interferon (gamma-INF) and interleukin-10 by peripheral blood mononuclear cells were measured. The serum concentrations of sIL-2R and the production of IL-10 were reduced (p < 0.05) after 2 months of treatment. Thus, this combination appeared to have immunomodulative potential in patients with advanced colorectal cancer.