Clinical impact of gastroenterologist-administered propofol during esophagogastroduodenoscopy: a randomized comparison at a single medical clinic.

BACKGROUND: Although midazolam is widely used during endoscopic procedures by endoscopists, propofol has been recently favored for its rapid action and metabolism. The aim of this study is to compare the clinical advantages between propofol and midazolam use during screening esophagogastroduodenoscopy (EGD) for gastric cancer and post-procedure management at a medical clinic. METHODS: One hundred six healthy patients aged 20-69 years requesting sedation for screening EGD from October 2012 to May 2013 at a single clinic in Japan were randomly assigned to propofol (n = 54) or midazolam (n = 52). Medications were given by bolus injection, and the dose was adjusted by body weight. Sedation level and tolerability during EGD and recovery time were assessed. Sedation level and tolerability were evaluated by American Society of Anesthesiologists responsiveness levels and four levels of the gag reflex, respectively. For safety purposes, endoscopists and nurses were trained in administering propofol and an anesthesiologist was on call at all times. RESULTS: No statistically significant differences were found between the two groups in sedation level and patient tolerability. Full recovery time in the propofol group (4.7 min) was significantly shorter than that in the midazolam group (24 min, P < 0.01). CONCLUSIONS: Regarding post-procedure management of patients in a medical clinic, propofol use might not necessitate a recovery room and excessive assessment tasks because of rapid recovery time without any prolonged reaction, which causes patient compliance. ( CLINICAL TRIAL REGISTRATION NUMBER: UMIN000009142.).

[A clinical study of therapy for local recurrent rectal cancer].

To evaluate the therapy for local recurrent rectal cancer, we examined clinicopathological characteristics and prognoses of 54 local recurrent rectal cancer patients. The cumulative 5 year survival rate was 20.3%, 3-year survival rate was 74% for a curative surgery group, 21.8% for a non-curative surgery group and 0% for a non surgery group. There were significant differences in the rates of three year survival between the curative surgery group and non surgery group, but there were no differences between the non curative surgery group and non-surgery group. A survival analysis showed that prognoses of patients ew (-) or CEA under 10 ng/ml group were statistically better than the other group. Thirty four patients underwent operation. The mean operation time and the mean blood loss were 334.2 minutes and 1977 ml, respectively. Eighteen patients had some complications associated with the operation. Radiotherapy and chemotherapy did not contribute to improve survival rate, but contribute to improved symptoms. In conclusion, curative surgery is the only therapy for local recurrent rectal cancer to improve survival rates, but there are many complications associated with non curative surgery. We therefore must evaluate the indication of operation carefully.

Randomized trial of adjuvant chemotherapy with mitomycin, Fluorouracil, and Cytosine arabinoside followed by oral Fluorouracil in serosa-negative gastric cancer: Japan Clinical Oncology Group 9206-1.

PURPOSE: To evaluate the survival benefit of adjuvant chemotherapy after curative resection in serosa-negative gastric cancer patients (excluding patients who were T1N0), we conducted a multicenter phase III clinical trial in which 13 cancer centers in Japan participated. PATIENTS AND METHODS: From January 1993 to December 1994, 252 patients were enrolled into the study and allocated randomly to adjuvant chemotherapy or surgery alone. The chemotherapy comprised intravenous mitomycin 1.33 mg/m2, fluorouracil (FU) 166.7 mg/m2, and cytarabine 13.3 mg/m2 twice weekly for the first 3 weeks after surgery, and oral FU 134 mg/m2 daily for the next 18 months for a total dose of 67 g/m2. The primary end point was relapse-free survival. Overall survival and the site of recurrence were secondary end points. RESULTS: Ninety-eight percent of patients underwent gastrectomy with D2 or greater lymph node dissection. There were no treatment-related deaths and few serious adverse events. There was no significant difference in relapse-free and overall survival between the arms (5-year relapse-free survival 88.8% chemotherapy v 83.7% surgery alone; P =.14 and 5-year survival 91.2% chemotherapy v 86.1% surgery alone; P =.13, respectively). Nine patients (7.1%) in the chemotherapy arm and 17 patients (13.8%) in the surgery-alone arm had cancer recurrence. CONCLUSION: There was no statistically significant relapse-free or overall survival benefit with this adjuvant chemotherapy for patients with macroscopically serosa-negative gastric cancer after curative resection, and there was no statistical difference between the two arms relating to the types of cancer recurrence. We do not recommend adjuvant chemotherapy with this regimen for this population in clinical practice.

[A case report of recurrence of liver metastases from colorectal cancer, which seemed to have vanished for a time by intra-aortic chemotherapy].

A 66-year-old man underwent lower anterior resection for rectum cancer with multiple liver metastases. The diagnosis was Stage IV well-differentiated tubular adeno carcinoma. n1H3M(-). As adjuvant chemotherapy, we chose intra-arterial infusion of 5-FU 1,500 mg/body/week from July 2002 to February 2003. The metastatic focuses have become smaller and smaller until they seemed to be scars. In July 2003, there appeared to be a liver metastasis again, which emerged at the same place of the first metastatic focus. We tried intra arterial infusion of DXR in addition to intra-venous infusion of CPT-11, but it seemed to have no effect. Finally, we performed a partial resection of the liver in March 2005. There were many metastatic legions that emerged, but we successfully carried through partial resections for all legions. The uniqueness of this case was the liver metastasis that had appeared at the same place of the first metastatic focus. As the strategy for liver metastasis of colon cancer, it is better to perform a surgical resection as soon as the focus becomes resectable.

[Indication and meaning of hepatic resection for metastatic liver tumors from gastric cancer].

To clarify the efficacy and indication of hepatectomy in gastric cancer metastasis to the liver, we studied 26 liver metastases patients undergoing hepatectomy. The cumulative 5-year survival rations were 25.3%. A survival analysis showed that prognoses of patients n(-) or T2 group were statistically better than other group. Three patients underwent a repeat liver resection from gastric metastasis and survived for about thirty months. There was an example using chemotherapy which made a liver tumor removal operation possible to the patient who had multiple liver metastases. In conclusion, liver resection is a beneficial option and multimodal therapy including a repeat liver resection and systemic chemotherapy, may be important for improving the prognosis of patients with liver metastases from gastric cancer.

[A case of advanced gastric cancer responding to neoadjuvant TS-1/CDDP chemotherapy].

The patient was a 61-year-old man who was referred to our hospital with a complaint of epigastric pain. Upper gastrointestinal endoscopy and X-ray examination of the stomach revealed type 3 cancer in the gastric antrum, extending to the middle body. It was about 9 cm in diameter, and the biopsy specimen revealed moderately differentiated tubular adenocarcinoma. Abdominal CT scan showed marked enlargement of No. 3 lymph nodes along the lesser curvature of the stomach. Examination of the blood showed a hemoglobin of 10.2 g/dl, CEA 5.8 ng/ml, CA19-9 330.5 U/ml. For this gastric cancer, clinical Stage IIIA (cT3N1HOPOMO), neoadjuvant chemotherapy with TS-1/CDDP was planned. TS-1 (120 mg/day) was orally administered for 3 weeks followed by a drug-free-2-week period as the first course, and 93 mg (60 mg/m2) of CDDP administered by intravenous drip on day 8. There were grade 2 nausea and grade 3 appetite loss by intravenous administration of CDDP in the second course. An upper GI series revealed 33% reduction of gastric cancer, and laboratory studies CEA and CA 19-9 showed normal values. One month after the second course of chemotherapy, total gastrectomy, splenectomy and lymph node dissection D2 were performed. The pathological specimens showed no cancer cells in the surgically obtained stomach and lymph nodes, so the histological effect was Grade 3. The postoperative course was satisfactory, and he now attends outpatient department without any findings of recurrence 12 months after the operation. TS-1/CDDP chemotherapy produced a high response in this case, and it may be useful as neoadjuvant chemotherapy for advanced gastric cancer.

[Local recurrence of pancreatic cancer successfully treated with gemcitabine].

We report a patient for whom systemic chemotherapy using gemcitabine was effective against local recurrence of pancreatic cancer. A 58-year-old man underwent pancreatoduodenectomy for a pancreatic head cancer. The diagnosis was Stage IVb poorly-differentiated tubular adenocarcinoma, scirrhous type, pT4, PL (+), P0, H0, pN2. However, after 21 months, gastrointestinal bleeding occurred. Gastroscopy and CT examination revealed a mass at the cut-end of the pancreas invading the stomach. The serum CA19-9 level was found to be elevated. Systemic chemotherapy was performed with a regimen of gemcitabine 1,000 mg/m2/week for 2 weeks, followed by a week rest. The recurrent tumor in the stomach disappeared, and the mass at the cut-end of the pancreas became small. The serum CA 19-9 level regained the normal value. Two years after the diagnosis of recurrence, he returned to work, and his chemotherapy is being continued as an outpatient.

Clinicopathological features and outcome of hepatic resection for liver metastasis from gastric cancer.

BACKGROUND/AIMS: The efficacy of operative resection of lesions metastatic to the liver from colorectal or neuroendocrine tumor is well established. However, the appropriate management of liver metastasis from gastric cancer is controversial. We analyzed the prognostic factors in patients who underwent hepatectomy for metastasis from gastric cancer. METHODOLOGY: Retrospective clinical and pathological study in Tokyo Metropolitan Bokutoh Hospital. Ten patients underwent hepatectomy for metastases from gastric cancer out of 1807 patients with gastric cancer between 1981 and 1998. INTERVENTIONS: Clinical investigation and histopathological examination of resected specimen. MAIN OUTCOME MEASURES: Survival, recurrence, liver metastases and lymph node metastases. RESULTS: The 1-, 3-, and 5-year survival rates of these ten patients were 50%, 30%, 20%, respectively. The median survival time was 25 months, and two patients survived longer than five years. The survival time tended to be longer, but not to a significant extent, in patients with no lymph nodal involvement at the primary site (P = 0.067). CONCLUSIONS: Even though it is rare, a survival time of 5-years can be achieved by resection of gastric cancer metastatic to the liver. These results suggest that a patient with liver metastasis from gastric cancer has a greater chance of surviving long-term if there is no lymph node metastasis at the primary site.

[Successful treatment of gastric cancer accompanied by multiple liver metastases with TS-1 followed by curative gastrectomy affiliation].

Despite the improvement in the operative results for patients with gastric cancer, the prognosis of those with liver metastasis remains dismal. Multimodal therapy has attracted considerable attention as a breakthrough in the strategy for treating cases of highly advanced gastric cancer. We report the case of a 62-year-old female with gastric cancer accompanied by multiple liver metastases successfully treated by TS-1, a novel oral fluoropyrimidine derivative. One treatment course consisted of 4 weeks of TS-1 administration (100 mg daily) followed by a 2-week break. After 3 courses of treatment, an abdominal CT scan showed no evidence of liver metastases and gastroscopy revealed that the primary gastric lesion was reduced. Grade 1 toxicity (nausea and diarrhea) was seen but 6 days rest improved the condition. Distal gastrectomy was subsequently performed without any finding of residual tumor. TS-1 may have a promising role in neoadjuvant chemotherapy for gastric cancer.

[A clinical scoring system may identify good candidates for hepatic arterial infusion chemotherapy after hepatic resection for colorectal cancer].

The significance of hepatic arterial infusion chemotherapy (HAI) for the prognosis of metastatic colorectal cancer is controversial. We applied a clinical scoring system to find good candidates for HAI after hepatic resection. Ninety-four consecutive cases of hepatic metastases resected at a single institute were analyzed retrospectively. The cases were divided into 4 subgroups: those with a low risk score (0-2 points) with and without HAI and those with a high risk score (3-5 points) with and without HAI. The number of cases and the cumulative 5 year survival rate of each case were as follows: low risk score with HAI (n = 17) 64.1%, low risk score without HAI (n = 25) 27.4%, high risk score with HAI (n = 28) 16.9%, and high risk score without HAI (n = 24) 14.7%, respectively. These results suggest that hepatic resection with HAI seemed to contribute to the outcome for selected cases. The clinical scoring system may identify good candidates for HAI as well as predict recurrence after hepatic resection for metastatic colorectal cancer.

Prognostic value of concomitant resection of extrahepatic disease in patients with liver metastases of colorectal origin.

BACKGROUND: Operative resection is the treatment of choice for colorectal liver metastasis. In the present study, we investigated the prognostic factors after hepatic resection, focusing on the concomitant resection of extrahepatic metastases. METHOD: A retrospective cohort study was performed in 187 consecutive patients who had undergone initial hepatic resections for colorectal metastases using the Cox proportional hazards model. RESULTS: The overall survival rates at 3, 5, and 10 years were 49%, 30%, and 22%, respectively. Hilar lymph node involvement (HLN), localized peritoneal seeding (P), and distant organ metastasis (M) were resected in addition to the liver metastases in 9, 13, and 21 patients, respectively. The P and M factors were related univariately to an unfavorable patient prognosis, but the HLN factor was not. In a multivariate regression analysis, the hazard ratios of these three factors of interest were 1.58 (HLN; 95% confidence interval 0.64-2.52, median survival 48 months), 2.12 (P; 1.38-2.85, 18 months), and 3.07 (M; 2.45-3.68, 19 months), respectively. CONCLUSION: Aggressive operative resection for colorectal liver metastases yielded an acceptable long-term outcome. The presence of distant organ metastasis seems to be a contraindication for operative intervention and/or resection; although the number of patients enrolled in the present study was small, resection of localized peritoneal seeding or hilar lymph node involvement, in addition to the resection of the liver metastases, may benefit patient survival.