Phase I/II trial of 2-weekly docetaxel combined with cisplatin plus fluorouracil in metastatic esophageal cancer (JCOG0807).

We carried out a phase I/II trial of adding 2-weekly docetaxel to cisplatin plus fluorouracil (CF) therapy (2-weekly DCF regimen) in esophageal cancer patients to investigate its safety and antimetastatic activity. Patients received 2-weekly docetaxel (30 mg/m(2) [dose level (DL)1] or 40 mg/m(2) [DL2] with a 3 + 3 design in phase I, on days 1 and 15) in combination with fixed-dose CF (80 mg/m(2) cisplatin, day 1; 800 mg/m(2) fluorouracil, days 1-5) repeated every 4 weeks. The primary endpoint was dose-limiting toxicity (DLT) in phase I and central peer review-based response rate in phase II. At least 22 responders among 50 patients were required to satisfy the primary endpoint with a threshold of 35%. Sixty-two patients were enrolled in phase I and II. In phase I, 10 patients were enrolled with DLT of 0/3 at DL1 and 2/7 in DL2. Considering DLT and treatment compliance, the recommended phase II dose was determined as DL1. In phase II, the response rate was 62% (P < 0.0001; 95% confidence interval, 48-75%); median overall survival and progression-free survival were 11.1 and 5.8 months, respectively. Common grade 3/4 adverse events were neutropenia (25%), anemia (36%), hyponatremia (29%), anorexia (24%), and nausea (11%). No febrile neutropenia was observed. Pneumonitis caused treatment-related death in one patient. The 2-weekly DCF regimen showed promising antimetastatic activity and tolerability. A phase III study comparing this regimen with CF therapy is planned by the Japan Clinical Oncology Group. This study was registered at the UMIN Clinical Trials Registry as UMIN 000001737.

Acase of advanced colon cancer arising from a colonic graft foran esophago-bronchial fistula : A case report.

Neoplasm of a colonic graft after esophageal reconstruction is rare. We treated a colon cancer patient who developed malignancy in a colonic graft after esophagectomy and reconstruction through a retrosternal route. A male had undergone esophagectomy in his 50s due to a benign esophago-bronchial fistula. His dysphagia became exacerbated 20 years later, and further examinations showed a circumferential tumor on the esophagocolonic anastomosis. He underwent resection of the colonic graft adenocarcinoma with median sternotomy after neoadjuvant chemotherapy. Gastric tube reconstruction was performed through a retrosternal route. This report should be informative in terms of making decisions from an initial reconstruction to follow-up and choosing a therapeutic strategy for colonic graft cancer in the future. J. Med. Invest. 66 : 190-193, February, 2019.

Ultrasonographic comparison of gastric motility between diabetic gastroparesis patients with and without metabolic syndrome.

BACKGROUND AND AIMS: Diabetic patients with poor glycemic control or long standing disease often have impaired gastric motility. Recently, metabolic factors such as blood glucose have been reported as influencing gastric motility independently of autonomic neuropathy. Many diabetic patients have metabolic syndrome, which is strongly associated with coronary and other diseases. We investigated whether metabolic syndrome influences diabetic gastroparesis patients. METHODS: We observed gastric motility ultrasonographically in diabetic gastroparesis patients including nine with and nine without metabolic syndrome. Both groups complained of upper abdominal symptoms when hospitalized to improve blood sugar control. All patients underwent upper gastrointestinal endoscopy to rule out gastric and duodenal lesions. All had autonomic neuropathy. Gastric motility was evaluated within 3 days after admission by transabdominal ultrasonography after a test meal. RESULTS: Gastric emptying was 45.0 +/- 13.7% in patients with and 39.1 +/- 11.9% in patients without metabolic syndrome, which was not statistically significant. Frequency of gastric contractions was 8.33 +/- 2.78 per 3 min in patients with metabolic syndrome and 7.44 +/- 2.13 per 3 min in the others, which was not statistically significant. The motility index, which involves antral contractility, was 3.21 +/- 2.18 in patients with metabolic syndrome and 2.80 +/- 1.87 in the others, which was not statistically significant. CONCLUSIONS: Metabolic syndrome did not appear to contribute to delayed gastric motility in diabetic gastroparesis.

A patient with esophageal hemangioma treated by endoscopic mucosal resection: a case report and review of the literature.

In a 58-year-old male, upper digestive endoscopy revealed a protruding lesion in the esophagus on a medical examination. The patient was referred to the Department of Surgery in our hospital to undergo surgery. On the initial consultation, upper digestive endoscopy showed a smooth, soft, black purple, type II protruding lesion measuring approximately 25 mm at 35 cm apart from the incisor. For diagnostic treatment and patient's request, endoscopic mucosal resection (EMR) was performed. The resected specimen measured 25 mm x 25 mm. The histological findings suggested cavernous hemangioma. To treat esophageal hemangioma, esohagectomy, tumor enucleation, or sclerotherapy has been performed. However, recently, thorough preoperative examination, such as endoscopic ultrasonography (EUS), has facilitated endoscopic resection, such as EMR.

Ultrasonographic assessment of gastric motility in diabetic gastroparesis before and after attaining glycemic control.

BACKGROUND: Glycemic control is important for maintaining gastric motility in diabetic patients, but gastric motility has not yet been studied ultrasonographically in relation to glycemic control. METHODS: We made such observations before and after establishing glycemic control in diabetic patients with gastroparesis. We studied 30 diabetic patients with upper abdominal digestive symptoms who were hospitalized for correction of poor blood sugar control and who underwent upper digestive tract endoscopy to rule out structural causes such as gastric/duodenal lesions. Gastric motility was evaluated by transabdominal ultrasonography, using a test meal, before and after attainment of glycemic control (within 3 days after admission and 3 days before discharge). Also, upper abdominal digestive symptoms present on admission and at discharge were compared. RESULTS: After glycemic control was established, contractions of the antral region were more frequent than before the attainment of control (8.93 +/- 1.17/3 min vs 7.63 +/- 2.22/3 min, respectively; P < 0.001). Glycemic control also significantly improved gastric emptying (before glycemic control, 49.2 +/- 14.8%; after, 67.1 +/- 11.5%; P < 0.001). This was also true for the motility index, concerning antral gastric contractility (before control, 2.97 +/- 1.57; after, 3.75 +/- 1.09; P < 0.05). Upper abdominal symptom scores were also significantly lower after attainment of control than before (0.47 +/- 0.78 vs 3.17 +/- 2.00, respectively; P < 0.001). CONCLUSIONS: These findings suggest that attaining glycemic control improves gastric motility and attainments upper abdominal symptoms in diabetic patients with gastroparesis.

Laparoscopic permanent sigmoid stoma creation through the extraperitoneal route.

About 50% of patients who have a permanent stoma experience some degree of parastomal hernia formation. To prevent this complication, the extraperitoneal route is considered to be more effective than the transperitoneal route in the case of open colorectal surgery. This technique also has superiority in avoiding postoperative intestinal obstruction. Although laparoscopic surgery for rectal cancer has not been proved to be as safe as open surgery by a randomized-controlled trial, some studies have shown the equality of long-term results with laparoscopic low anterior resection and laparoscopic abdominoperineal resection. It is anticipated that cases of laparoscopic abdominoperineal resection will increase in the near future. However, a laparoscopic technique for creation of a permanent stoma has hardly been discussed. Most operative procedures for laparoscopic stoma creation have been performed with transperitoneal route, which may cause parastomal hernia and/or intestinal obstruction. This report describes a laparoscopic technique for permanent sigmoid stoma creation through the extraperitoneal approach.

Resected xanthogranulomatous pancreatitis.

Xanthogranulomatous changes in the pancreas are extremely rare. A 66-year-old man presented with a 2-year history of epigastralgia. Computed tomography scan revealed a 4-cm low-density area around the body of the pancreas. Magnetic resonance imaging demonstrated that the mass appeared hyperintense on a T2-weighted image and isointense on a T1-weighted image. Based on a diagnosis of invasive ductal carcinoma of the pancreas, distal pancreatectomy and splenectomy were performed. Sections examined from the mass showed an aggregation of many foamy histiocytes, lymphocytes, and plasma cells. The surrounding pancreatic tissue showed fibrosis and chronic inflammation. These findings suggested a xanthogranulomatous inflammation, and resulted in a diagnosis of xanthogranulomatous pancreatitis.

New laparoscopic double-stapling technique.

BACKGROUND: Laparoscopic surgery for colon cancer has been shown by several randomized, controlled trials to be an acceptable alternative to open surgery; however, laparoscopic rectal surgery has not been evaluated in a randomized trial. One of the most serious problems associated with laparoscopic rectal surgery are bowel clamping, irrigation, and transection of the rectum, and laparoscopic rectal surgery has not been as reliable as open rectal surgery. MATERIALS AND METHODS: We present our new technique, the laparoscopic double-stapling technique, which eliminates these problems. This technique uses curved Doyen forceps introduced through the wound just above pubis symphysis for clamping the rectal wall at the anal side of the tumor. An endolinear stapler (length 60 mm) is inserted through the same wound, applied at the rectal wall parallel and caudal to the Doyen forceps, and transects the rectum under pneumoperitoneum. We used this technique for eight cases of rectal surgery. RESULTS AND DISCUSSION: The laparoscopic double-stapling technique provided secure bowel clamping and rectal irrigation. The number of cartridges used in laparoscopic double-stapling technique cases was not more than 2, with an average of 1.6 per patient. None of the laparoscopic double-stapling technique cases experienced major complications. CONCLUSION: We consider that many cases of rectal cancer that are suitable for laparoscopic low anterior resection can undergo laparoscopic surgery by using this technique, which will improve the quality of rectal surgery.