[Perioperative management of two patients with renal malignant tumor involving the vena cava].

Two patients underwent resection of renal malignant tumors involving vena cava. Such tumors occasionally extend to the inferior vena cava with tumor thrombus and invasion to the lymph nodes and adjacent organs. Perioperative management of patients with these tumors is difficult because of the risk of pulmonary embolism and massive bleeding, and requires appropriate cooperation among the surgical team. In case 1, a 56-year-old man, renal cell carcinoma with tumor thrombus had extended into the intrahepatic vena cava. It was resected after isolating the liver from vena cava and incising the cross-clamped inferior vena cava without extracorporeal circulation or blood transfusion. A prosthetic graft replaced the inferior vena cava. In case 2, a 64-year-old woman, renal pelvis cancer adhered to the inferior vena cava and the mesentery with enlarged lymph nodes. It was separated from the inferior vena cava and removed with the ascending colon. The patient received a blood transfusion of approximately 2,000ml. Cardiomyopathy associated with a left ventricular outflow tract pressure gradient of 100mmHg required perioperative management. After surgery, both patients underwent controlled ventilation in the intensive care unit. After recovery, they were discharged without complications. We discuss perioperative management, with regard to the level of the tumor extension and perioperative complications.

Obstructive Colitis with Minor Perforation Induced by Double Sigmoid Adenocarcinoma.

A 72-year-old women was referred to our hospital because of lower left abdominal pain. Computed tomography showed prominent sigmoid colon dilation and double tumors on both the oral and anal sides. Surgical resection revealed an expanded sigmoid colon involved in double cancer that showed strong adhesion to the surrounding tissues. The pathological findings revealed obstructive colitis and minor perforation in the dilated colon. The minor perforation was considered to have been caused by fecal impaction in the closed cavity between the two tumors, resulting in an increase in colon pressure.

Therapeutic value of lymph node dissection in advanced gastric cancer with macroscopic duodenum invasion: is the posterior pancreatic head lymph node dissection beneficial?

BACKGROUND: In advanced gastric cancer (AGC) with duodenum invasion, the posterior pancreatic lymph nodes are susceptible to metastasis because of their proximity to the duodenum. The therapeutic value of lymph node dissection in this area for AGC with macroscopic duodenum invasion remains unclear. METHODS: Patients who had undergone curative gastrectomy for lower-third AGC from 1970 to 2004 at the Cancer Institute Hospital were recruited for this study. Clinicopathological data were collected retrospectively, and compared between cases of AGC with duodenum invasion (AGC-DI group) and AGC without duodenum invasion (AGC-nDI group). In the AGC-DI group, the therapeutic value of lymph node dissection was evaluated using a therapeutic index (multiplication of the frequency of metastasis to the station by the 5-year survival rate of patients with metastasis to that station). RESULTS: The AGC-DI group generally had tumors of higher pathological stage, which might account for the poorer 5-year survival rate compared with that of the AGC-nDI group (50.1% versus 68.5%; P = 0.0002). The incidence of lymph node metastasis was higher in the AGC-DI group than that in the AGC-nDI group, including nodes in the posterior pancreatic head (23.9% versus 7.0%, P < 0.0001). In the AGC-DI group, posterior pancreatic head lymph node dissection was of therapeutic value (4.19) equivalent to dissection of second-tier lymph nodes. CONCLUSIONS: The dissection of posterior pancreatic head lymph nodes might be effective in AGC with macroscopic duodenum invasion since this has therapeutic value equivalent to that of second-tier lymph node dissection and might improve patients' long-term outcomes.

The benefits of standardizing the operative procedure for the assistant in laparoscopy-assisted gastrectomy for gastric cancer.

BACKGROUND AND AIM: Laparoscopy-assisted distal gastrectomy (LADG) has not yet been widely adopted for the treatment of gastric cancers because of the perceived complexity of the procedure. In addition to the proficiency of the operator, other factors could potentially be optimized to improve postoperative outcomes. The aim of this study was to evaluate a standardized operative procedure for assistants performing LADG. MATERIALS AND METHODS: Of 114 patients, 64 initially underwent conventional LADG (CLDG) and then 50 underwent standardized procedure (SLDG) in which the role of assistant in LADG was completely established. Parameters compared for the SLDG and CLDG groups were operation time, estimated blood loss, intra- or postoperative complications, preservation of the vagus nerve, and the number of pathologically examined lymph nodes. RESULTS: The operation time for the SLDG procedure (mean +/- SE, 229 +/- 6 min) was shorter than for the CLDG procedure (261 +/- 8 min; P < 0.002), and the estimated blood loss for SLDG (57 +/- 7 ml) was less than for CLDG (108 +/- 17 ml, P < 0.004). The celiac branch of the vagus nerve was preserved in 73% of SLDG patients compared with 52% of CLDG patients (P < 0.03). More lymph nodes were pathologically examined in SLDG patients (38.3 +/- 1.5) than in CLDG patients (32.5 +/- 1.8, P = 0.02). CONCLUSIONS: Standardization of the LADG procedure for assistants enabled a shorter operation time, reduced blood loss, a higher rate of vagus nerve preservation, and more accurate lymph node dissection.

Risk of gastric cancer after Roux-en-Y gastric bypass.

OBJECTIVE: To evaluate the risk of gastric cancer after Roux-en-Y gastric bypass (RYGB). DESIGN: Rats randomly underwent 1 of the following: RYGB, duodenojejunal bypass (DJB), or a sham operation. Postoperatively, rats underwent a protocol of cancer induction by means of both continuous (200 ppm in tap water for 16 weeks) and intermittent (50-mg/kg intraesophageal injection, once a week, for 12 weeks) administration of N-methyl-N-nitrosourea. SETTING: Institut de Recherche Contre les Canceurs de l'Appareil Digestif-European Institute of Telesurgery. STUDY ANIMALS: Fifty-five Fischer 344 rats. MAIN OUTCOME MEASURES: Seventeen weeks after the operation, we performed a pathologic examination of the whole stomach in all animals to assess for the presence of cancer and/or premalignant lesions. Bilirubin concentration, gastric bacterial flora, and any other pathologic findings were also recorded. RESULTS: In rats in the sham and DJB groups, the incidence of gastric cancer was 85% and 75%, respectively (P = .63), whereas only 23% of rats in the RYGB group developed gastric cancer (4-fold reduction; P = .002). The remnant stomach of rats in the RYGB group also showed a lower bilirubin concentration (P < .01) and a lower bacterial count (P < .05) compared with both the DJB and sham groups. CONCLUSIONS: This study shows that RYGB reduces the risk of gastric cancer in an experimental model of dietary-induced carcinogenesis. Lack of direct contact with carcinogens, lower bile reflux, and a lower bacteria concentration in the gastric content may be responsible for these observations. These data suggest that RYGB may be a safe option for the treatment of morbid obesity even in areas with high gastric cancer incidence.

Prognostic significance of fascin overexpression in human esophageal squamous cell carcinoma.

PURPOSE: Fascin, an actin bundling protein, induces membrane protrusions and increased cell motility in various transformed cells. The expression of fascin in epithelial neoplasms has been described only recently, and the role of fascin in esophageal squamous cell carcinoma (ESCC) is still unknown. EXPERIMENTAL DESIGN: Paraffin sections of 200 patients with ESCC were immunohistochemically investigated. The expression levels of fascin mRNA in 20 ESCC tissues were compared with that in corresponding normal esophageal epithelium by semiquantitative reverse transcription-PCR. We also examined fascin protein expression in 33 ESCC cell lines. The role of fascin in cell motility and invasiveness in ESCC cells was assessed by the vector-based small interfering RNA. RESULTS: In immunohistochemical study, the intensity of fascin expression was usually increased in the tumor compared with that in normal epithelium. Fascin overexpression was significantly associated with a poor prognosis (immunoreactive rate, P = 0.033; immunoreactive intensity, P = 0.031). The fascin immunoreactive rate was associated with extent of the tumor (P = 0.002) and lymph node metastasis (P = 0.003). Multivariate analysis showed that fascin expression intensity was an independent prognostic factor, but the immunoreactive rate was not. In addition, up-regulation of fascin mRNA was found in 60% (12 of 20) of patients. In vitro study revealed that all 33 ESCC cell lines expressed fascin protein at a certain level. KYSE170, one of the fascin-overexpressed cells, decreased its motile and invasive properties after down-regulation of fascin expression. CONCLUSION: Our findings suggest that fascin overexpression may play an important role in the progression of ESCC.

In vivo evaluation of a new composite mesh (10% polypropylene/90% poly-L-lactic acid) for hernia repair.

The increasing use of mesh insertion for groin hernia repair is dashed by a worrying prevalence of chronic pain frequently related as a reaction to the biomaterial implantation. Thus, new biocompatible prosthesis, designed as a composite material associating polypropylene (PP) and long-term absorbable material, are now under development. In the present study, the typical commercially available Prolene mesh has been compared to two new meshes designed with 3-fold less PP, either alone (light PP) or associated with poly-L-lactic acid (PP-PLA) accounting for 90% of the mesh weight. These PP-mesh variants were implanted in an extraperitoneal position within the abdominal wall of 90 rats. Mesh adhesion and size were determined at autopsy 2, 4 and 8 weeks after implantation (10 animals per group) and morphometric parameters of the host tissues by light microscopy. Prolene and light PP-meshes presented intra-corporeal shrinkage and tissue adhesion, both more pronounced with light-PP, whilst PP-PLA meshes were not affected in spite of a strongest fibrosis. In contrast to Prolene and even more with light PP meshes, inflammation and cell-mediated immune responses were reduced without occurrence of angiogenesis or oedema. All these findings advocate together for a better tolerance of this new composite biomaterial, more likely due to a low macrophage response that appeared statistically correlated to the absence of mesh shrinkage and to a decreased adhesion to the tissue. On the basis of these experimental observations, it could be expected that the better tolerance of this composite biomaterial may avoid both long-term pain and recurrence when used as plug in groin hernia repair.

Esophagojejunostomy through minilaparotomy after laparoscopic total gastrectomy.

Although laparoscopic distal gastrectomy (LDG) has been accepted as a surgical option for the treatment of early gastric cancer, laparoscopic total gastrectomy (LTG) has been adopted less often, because a more difficult surgical technique is required for reconstruction. To reduce the technical difficulties, we made some modifications to the functional end-to-end anastomosis technique and performed esophagojejunal anastomosis through a minilaparotomy. First, for easier handling of the esophagus, the first application of the linear stapler to create the esophagojejunal anastomosis was performed before transection of the esophagus. Second, the jejunal limb was anastomosed to the left side of the esophagus, which, compared with the right side, made available more free space, sufficient to operate the stapling device. Third, to close the entry hole and complete the gastrectomy concurrently, a linear stapler was applied through the left lower trocar. With this technique, the closure of the access opening was performed easily and was monitored directly through the minilaparotomy. We successfully performed LTG with Roux-en-Y reconstruction using our modified procedure in seven patients without any anastomotic complications. We believe our procedure is a secure and reliable method for reconstruction after LTG and will facilitate adoption of LTG as a surgical option for patients with early upper gastric cancers.

Clinical significance of osteopontin in esophageal squamous cell carcinoma: comparison with common tumor markers.

OBJECTIVE: Osteopontin (OPN) is a secreted integrin-binding glycophosphoprotein that may have a role in head and neck squamous cell carcinoma (SCC). To evaluate the clinical significance of OPN in esophageal squamous cell carcinoma (ESCC), we compared plasma OPN levels with those of common tumor markers. METHODS: Preoperative plasma OPN levels were measured by enzyme immunoassay in 103 ESCC patients. Serum SCC antigen, Cyfra 21-1, and carcinoembryonic antigen (CEA) levels were also measured routinely at admission by radioimmunoassay. RESULTS: Plasma OPN levels ranged from 82.8 to 1,980 ng/ml. High OPN level was associated with lymph node metastasis (p = 0.05), but not with tumor histology or depth of invasion. The overall survival of the patients with high OPN levels was worse than that of those with low OPN levels (p = 0.02). SCC antigen and Cyfra 21-1 levels were associated with the depth of tumor invasion, the tumor diameter, lymph node metastasis, and the overall survival, but CEA was not associated with these clinicopathological factors. Combined evaluation of OPN plus Cyfra 21-1 or OPN plus SCC antigen was useful as an independent prognostic indicator. CONCLUSION: Measurement of the plasma OPN level, as well as serum SCC antigen and Cyfra 21-1, may help to predict the progression of ESCC.