A Surgical Case of Primary Splenic Malignant Lymphoma Complicating Chronic Hepatitis C.

The patient was a 70-year-old man. Hepatic dysfunction was found in 1988 and chronic hepatitis C was diagnosed in 1993. He received interferon-alpha therapy, but did not respond to it. Thereafter, he was treated with ursodeoxycholic acid. In September 2010, abdominal ultrasound showed a hypoechoic tumor (29 × 25 mm) in the lower pole of the spleen, and this lesion became larger one year later (74 × 66 × 71 mm). Abdominal CT revealed a hypovascular heterogeneous tumor with smooth margins on both dynamic and delayed phase scans. MRI displayed a tumor with a low signal intensity on T2WI. Abdominal angiography confirmed that the lesion was hypovascular. 67Ga scintigraphy showed abnormal accumulation confined to the spleen. Bone marrow biopsy did not reveal any abnormalities. Based on these findings, primary splenic malignant lymphoma (PSML) complicating chronic hepatitis C was diagnosed and splenectomy was performed. A tumor (78 × 60 mm) was found in the lower pole of the resected spleen and pathologic examination revealed diffuse large B cell lymphoma (DLBCL). Four courses of postoperative R-CHOP therapy were performed. At present, he continues to use ursodeoxycholic acid with no recurrence after four years. In conclusion, we report our experience of a patient who had PSML complicating chronic hepatitis C with discussion of the literature.

Fundic rotation technique: a useful procedure for laparoscopic exogastric resection of gastric submucosal tumors located on the posterior wall near the esophagogastric junction.

OBJECTIVE: To develope a new procedure for laparoscopic exogastric resection using a so-called "fundic rotation technique (FRT)" for gastric submucosal tumors (SMTs) on the posterior wall near the esophagogastric junction (EGJ). METHODS: Between April 2006 and February 2010, we performed laparoscopic resection for SMTs located near the EGJ (within 3.0 cm from the EGJ) in ten consecutive patients. Out of seven exogastric resections, an FRT was used in five patients with posterior tumors near the EGJ. RESULTS: The patients comprised three men and two women, with an average age of 65 years. The maximum tumor diameter averaged 3.8 cm (range, 2.0-8.0 cm), and the average distance from the EGJ was 1.5 cm (range, 0-2.5 cm). The pathological diagnosis was GIST in all cases. One case was converted to an open surgery due to its large size (8.0 cm) and the difficult access. All the patients quickly returned to their normal activities. No patient complained any symptoms of regurgitation, and endoscopic examination revealed no remarkable reflux esophagitis. No tumor recurrences occurred during a median follow-up period of 30 months. CONCLUSION: The indications for laparoscopic resection of SMTs located near the EGJ may be extended using an FRT.

[Perforated peptic ulcer disease in the elderly].

There has been a marked decrease in elective surgery for peptic ulcer disease following introduction of medical therapies including H2-receptor antagonists (H2-RA) and proton pump inhibitors (PPI). By contrast, the incidence of emergency surgery for perforated peptic ulcer(PPU) has remained relatively unchanged, and potentially increased. Conservative treatment of PPU should be selected based on the physical condition of the patient. Open and laparoscopic repair of PPU are made with peritoneal lavage and omental patch closure of perforation. Laparoscopic repair of PPU seems better than open repair for low-risk patients. However, open repair for high-risk patients of PPU should not be delayed, and prognosis is affected primarily by concomitant medical comorbidity in the elderly.

Oligomerized grape seed polyphenols attenuate inflammatory changes due to antioxidative properties in coculture of adipocytes and macrophages.

Macrophage infiltration of white adipose tissue (WAT) is implicated in the metabolic complications of obesity. In addition, inflammatory changes through dysregulated expression of inflammation-related adipokines such as tumor necrosis factor-alpha (TNF-alpha) and monocyte chemoattractant protein-1 (MCP-1) in WAT are considered to be one of the causes of insulin resistance. Recently, enhanced oxidative stress in adipocytes has been reported to be implicated in dysregulated expression of inflammation-related adipokines. Polyphenols are well known as potent natural antioxidants in the diet. In the present study, we investigated the antioxidative effects of an oligomerized grape seed polyphenol (OGSP) on inflammatory changes in coculture of adipocytes and macrophages. Coculture of HW mouse white adipocytes and RAW264 mouse macrophages markedly increased the production of TNF-alpha, MCP-1 and plasminogen activator inhibitor-1 compared with control culture. Treatment of HW cells with OGSP significantly attenuated the dysregulated production of adipokines. Moreover, OGSP significantly suppressed coculture-induced production of reactive oxygen species (ROS). Although enhanced release of free fatty acids (FFAs) by coculture was not altered by OGSP, FFA-induced ROS production in HW cells was significantly attenuated by OGSP. Furthermore, OGSP significantly reduced increases in the transcriptional activity of nuclear factor-kappaB and activation of extracellular signal-regulated kinase by coculture. Thus, these results suggest that the antioxidative properties of OGSP attenuate inflammatory changes induced by the coculture of adipocytes and macrophages.

Laparoscopy-assisted combined resection for synchronous gastric and colorectal cancer: report of three cases.

In gastric cancer patients, the most common form of synchronous cancer is colorectal cancer. To reduce the invasiveness of the resection, a laparoscopy-assisted combined resection was performed in three patients with synchronous gastric and colorectal cancer. Although all gastric lesions were in the early stages, two colorectal lesions were advanced cases. In all cases, the laparoscopic gastric resection and reconstruction was performed first, followed by the colorectal resection. In the case of right-side colon cancer in addition to gastric cancer, it was relatively easy to perform the combined resection with lymph node dissection sharing the same ports used for the gastrectomy, although we needed an additional port. In one case, in which rectal cancer was present in addition to gastric cancer located in the upper portion of the stomach, a totally laparoscopic proximal gastrectomy was combined with a laparoscopy-assisted low anterior resection, leaving only a lower abdominal minilaparotomy wound. All patients quickly returned to normal activity without remarkable complications, with the exception of a wound infection in one patient. With a mean follow-up of 30.7 months, all patients survived without any sign of recurrence. This procedure represents a feasible option for minimally invasive treatment of synchronous gastric and colorectal cancer.

Endoscopy-assisted gastric resection: a safe and reliable procedure for tumor clearance during laparoscopic high distal or proximal gastrectomy.

BACKGROUND: Preoperative endoscopic tattooing or clipping is generally used to delineate the tumor-free margin in surgery for early gastric cancer. However, it is sometimes difficult to identify the line of resection during laparoscopic gastrectomy. METHODS: Between June 2003 and February 2008, we performed a total of 12 endoscopy-assisted gastric resections during laparoscopic gastrectomy for cancer, including four cases of high distal gastrectomy and eight cases of proximal gastrectomy. In the laparoscopic high distal gastrectomy cases, a surgeon performed transduodenal endoscopy to identify the clips before gastric resection. For totally laparoscopic proximal gastrectomy, an endoscopist performed transoral endoscopy to identify the clips placed in the distal margin of the lesion and to facilitate intracorporeal anastomosis. RESULTS: In all cases, we were able to observe clips as well as the primary lesion. Gastric resection was successfully performed with no positive margin. In the high distal gastrectomy group (n = 4), proximal and distal margins were 19.5 +/- 2.1 (range, 10-35) mm and 1,185 +/- 190.9 (range, 850-1,320) mm, respectively. In the proximal gastrectomy group (n = 8), proximal and distal margins were 21.3 +/- 7.1 (range, 5-38) mm and 47.5 +/- 3.5 (range, 15-75) mm, respectively. The intracorporeal side-to-side anastomosis during proximal gastrectomy was successfully performed using an endolinear stapler. CONCLUSIONS: Endoscopy-assisted gastric resection is a safe and reliable procedure for tumor clearance during laparoscopic high distal or proximal gastrectomy.

New method of laparoscopic incisional hernia repair with double circumferential transfascial sutures.

BACKGROUND: Although, laparoscopic incisional hernia repair (LIHR) provides an alternative method for managing incisional hernias, the ideal procedure for reducing the incidence of postoperative complications remains unclear. PATIENTS AND METHODS: We have developed a new method of LIHR that involves a double transfascial suture and does not require the use of spiral tackers. We performed this procedure consecutively in five patients (four males and one female with a mean age of 65.6 years). We describe our new method of LIHR, and present preliminary clinical results. RESULTS: The mean defect size was 26.2 ± 15.8 cm(2), and the mesh size that was used was 121.7 cm(2) in all cases. An occult hernia was found in one patient during laparoscopic observation. The mean operative time was 198.4 ± 49.3 minutes with a blood loss of 12.2 ± 24.6 mL. Postoperative courses were uneventful with a median postoperative hospitalization period of 8 days. No patient required mesh removal and none developed a recurrent hernia during the median follow-up period of 13 months. CONCLUSION: Although, larger number of patients and longer follow-up will be required to prove the operative adequacy of our new procedure, it appears to represent a feasible option for LIHR.

Clinical outcome of jejunal pouch double-tract reconstruction after total gastrectomy.

BACKGROUND/AIMS: The importance of the duodenal passage and the need for pouch reconstruction after total gastrectomy are matters of controversy. METHODOLOGY: Twenty consecutive patients with early gastric cancer were studied 20who underwent jejunal pouch double-tract (JPD) reconstruction after total gastrectomy. Nutritional variables were examined for > or =10 years postoperatively. RESULTS: The mean operation time was 204 minutes. There was no anastomotic leakage and no hospital mortality. Anastomotic stenosis between the esophagus and a jejunal pouch developed in 2 patients (10%), and reflux esophagitis was observed in 4 (20%). Symptoms were controlled by conserva tive treatment within 3 years after surgery. Body mass indices in all patients were significantly decreased from 1 month (p<0.05) to 10 years (p<0.005) after the operation. The mean body weight decrease occurring during the first to the tenth postoperative year was 12.7% overall, but 17.8% and 9.1% in patients aged > or =60 years and <60 years, respectively. The body weight decreases from 3 (p<0.05) to 6 (p<0.01), and at 9 years (p<0.01) were significantly lower before 60 years of age than after. CONCLUSIONS: JPD reconstruction facilitates long-term recovery of body weight after total gastrectomy and should be considered before the aged of 60.

Endoscopy-assisted totally laparoscopic resection of a submucosal tumor of the duodenum.

Although, endoscopic polypectomy is one of the first options for diagnosis and treatment of submucosal tumors of the duodenum, it is sometimes difficult for large or sessile tumors. Therefore, local excision or more extended surgery is performed under open laparotomy. In this paper, we present a laparoscopic resection of Brunner's gland hyperplasia of the duodenum which demonstrated rapid interval size change. A 73-year-old male with a histologically unproven submucosal tumor underwent endoscopy-assisted laparoscopic resection of the tumor and intracorporeal suturing of the defect. Simultaneous duodenoscopy and laparoscopy were performed to identify the line of resection. A duodenotomy was performed and the tumor was excised after everting the tumor toward the abdominal cavity. The defect was handsewn with the greater curvature side rolled caudally with an exteriorized stay suture. Postoperative pain was minimal and the patient quickly returned to normal activity. Our new technique provides a minimal invasive treatment for tumors of the duodenum.

A case of the primary small intestinal cancer which performed operation under laparoscopy after ileus decompression.

The patient was a 66-year-old man with repeated episodes of abdominal pain resulting in a diagnosis of ileus, and he was admitted to this hospital. During hospitalization, the pain symptoms improved after the insertion of an ileus tube, but there was a recurrence of ileus after the patient was started on a liquid diet. An adhesive intestinal obstruction was thus suspected, and laparoscopy was performed. A diagnosis of small intestinal carcinoma was made based on the intraoperative findings. A partial resection of the small bowel and a regional lymphadenectomy were performed through a minor laparotomy. The incidence of primary small intestinal cancer has been relatively rare, and it is difficult to differentiate the disease in most cases. A laparoscopy is considered useful to diagnose and treat ileus after decompression of the intestinal tract, and this article describes the case with some discussion.

Clinical outcome of proximal gastrectomy in patients with early gastric cancer in the upper third of the stomach.

OBJECTIVE: To determine whether clinical outcomes after proximal gastrectomy are better than those after total gastrectomy with Roux-en Y reconstruction. METHODS: We studied 10 consecutive patients with early gastric cancer who underwent esophagogastrostomy after proximal gastrectomy (PG group). Nutritional variables in these patients were compared with those in 10 consecutive patients who underwent Roux-en Y reconstruction after total gastrectomy (TG group). Patients were followed up for 5 years after operation. RESULTS: There was no anastomotic leakage. The total cholesterol level 1 year after operation was higher in the PG group than in the TG group (p< 0.05). Body mass index was significantly lower than the preoperative value between 1 month and 2 years postoperation in the PG group, whereas the TG group showed decreases between 3 months to 5 years postoperation. The percent decreases in body weight at 3 and 4 years in the PG group were lower than those in the TG group (both p< 0.05). Postoperative weight loss was thus milder in the PG group than in the TG group. CONCLUSION: Esophagogastrostomy after PG may produce better clinical outcomes than Roux-en Y reconstruction after TG in patients with early gastric cancer arising in the upper third of the stomach.

Esophagogastrostomy before proximal gastrectomy in patients with early gastric cancers in the upper third of the stomach.

OBJECTIVE: This study was designed to assess the outcome of esophagogastrostomy before proximal gastrectomy in patients with early gastric cancers in the upper third of the stomach. METHODS: From 1997 through 2004, we studied 10 consecutive patients. A stapler was introduced into the stomach, and an esophagogastrostomy was performed before proximal gastrectomy. Hill's posterior gastropexy and Dor's anterior fundic wrap were performed to prevent reflux esophagitis. RESULTS: The operation time was 171 ± 44 minutes, and the intraoperative bleeding volume was 294 ± 228 mL. There was no anastomotic leakage. Anastomotic stenosis, occurring in 40% of the patients, required endoscopic balloon dilatation. Symptoms of reflux esophagitis, occurring in 40% of the patients, resolved within 2 years after operation. As compared with the preoperative value, body mass index was significantly decreased 1 and 2 years after operation, but was similar at 3 to 5 years. The percent decrease in body weight after operation fluctuated between 6% and 8% between 2 and 5 years. Postoperative weight loss was thus mild. CONCLUSIONS: Esophagogastrostomy before proximal gastrectomy may be less invasive, simpler, and produce better outcomes than conventional procedures for the surgical treatment of early gastric cancer in the upper third of the stomach.

A case report of advanced thoracic esophageal cancer with severe malignant stricture.

We experienced one case with locally advanced esophageal cancer that he gained a good result by the multidisciplinary treatment including the operation followed by chemoradiation. The case was a 74-year old man with the middle thoracic esophageal cancer accompanied by severe malignant stricture. He couldn't take any water, and his general condition was poor, because he lost 5 kg of his weight. By the clinical examinations, his cancer had no apparent invasion to adjacent organ. So, we planned the operation gone ahead the chemoradiation for him to take water and meals earlier, and to prevent pneumonia. The esophagectomy through right-thoracotomy was done, and the pathological findings were type 3, well differentiated squamous cell carcinoma, pT3 N0, pStageII. Two months later after the operation, he took the chemoradiotherapy. 50 gray radiation therapy was done with chemotherapy including Cisplatin (10 mg/a time/week) and Tegafur (200 mg/day). About one and half a year after the operation, he sends good daily life with no recurrence. Recently, chemoradiotherapy is the first choice of the treatment for the locally advanced esophageal cancer. But in cases without apparent invasion to adjacent organ, it might be advisable that the operation goes ahead the chemoradiotherapy in the multidisciplinary treatment.

Focus on the conditions of resection and reconstruction in gastric cancer. What extent of resection and what kind of reconstruction provide the best outcomes for gastric cancer patients?

To assess the roles of the extent of gastric resection and duodenal food passage reconstruction in gastric cancer, we examined a consecutive series of 1,061 patients who underwent total or partial (proximal and distal) gastrectomies with or without duodenal food passage reconstruction between August of 1974 and January of 2002, and received gastrectomies with D2-3 lymph node dissection. Patients who underwent distal or proximal gastrectomy were found to have significantly better survival rates than those who underwent total gastrectomy in stages 1A (10-year survival: 86.6 and 78.9 vs. 61.6%), 2 (56.5 and 65.6 vs. 34.4%), 3A (45.9 and 33.3 vs. 15.2%), and 4 (5-year survival rates: 23.7 and 50.0 vs. 7.1%). Additionally, patients with duodenal food passage reconstruction or double tract reconstruction also showed significantly better survival rates than those without duodenal food reconstruction in stages 1A (10-year survival: 86.4 and 82.5 vs. 61.7%), 1B (69.9 and 90.6 vs. 54.1%), 2 (60.5 and 63.3 vs. 16.5%), and 3A (39.9 and 47.4 vs. 23.1%). In multivariate analysis, the independent prognostic factors were age at operation, depth of tumor, duodenal food passage reconstruction, and lymph node metastasis. Our results indicate that both the extent of gastric resection and duodenal food passage reconstruction were important factors in the outcome of gastric cancer patients, and that surgeons should perform minimal gastric resection with preservation of the duodenal food passage when the gastric stump is tumor-free.

Effect of pouched reconstruction after total gastrectomy on ERCP and ENBD--report of two cases.

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic nasobiliary drainage (ENBD) are well known to be useful but these procedures are rarely indicated in patients after total gastrectomy, because the endoscopic approach is more difficult in the patients with standard reconstructions such as Roux-en-y esophagojejunostomy after total gastrectomy. Gastric replacement with various enteric reservoirs after gastrectomy has been used to improve the postprandial symptoms and nutrition of patients after total gastrectomy. We have been performing jejunal pouch double tract reconstruction (JPD) after gastrectomy and the patients' postoperative course has been satisfactory. In this report, we describe two cases of biliary tract disorders after total gastrectomy. One was choledocholithiasis and the other was bile leakage after cholecystectomy. In each case, we performed ERCP, and treated with ENBD tube placement, and we obtained satisfactory results. We emphasize that ERCP and ENBD are also useful and easy procedures for biliary tract disease in postgastrectomy patients with JPD reconstruction as well as in patients who have not undergone intestinal reconstruction. The advantages of JPD reconstruction are not only improving the postprandial symptoms and the nutrition of patients after total gastrectomy, but that it provides an easy endoscopic approach to the papilla of Vater.