Simple and reliable method for tumor localization during totally laparoscopic gastrectomy: intraoperative laparoscopic ultrasonography combined with tattooing.

We have developed a new method to localize a tumor during totally laparoscopic gastrectomy that uses intraoperative laparoscopic ultrasonography combined with preoperative clipping and tattooing. One or 2 days before the surgery, endoscopic clipping was performed just proximal to the tumor, followed by tattooing with India ink at the clipping site. Examination by intraoperative laparoscopic ultrasonography was performed at the tattooed site to detect the clips. The resection line of the stomach was determined with use of the detected clips as a marker of the proximal margin of the tumor. This method was attempted in 14 patients who underwent totally laparoscopic gastrectomy, and the clips were successfully identified in all patients. The clips were visualized as several layers of a hyperechoic bar, which was termed a "ladder sign." The mean time from insertion of the laparoscopic probe to identification of the clips was 2 min. The ladder sign is an important finding in this method.

Asbestos exposure increases the incidence of histologically confirmed usual interstitial pneumonia.

AIMS: We hypothesized that asbestos exposure increases the incidence of macroscopically visible and histologically confirmed usual interstitial pneumonia (histological UIP). METHODS AND RESULTS: We retrospectively examined 1718 cases (1202 males; mean age 66.7 years) who underwent lobectomy for resection of pleuropulmonary tumours. Objective markers for asbestos exposure included: the presence of malignant pleural mesothelioma, the presence of pleural plaques (PPs) and asbestos bodies in the histological specimen. Risk factors for histological UIP were examined. Two separate groups were studied: 183 with asbestos exposure, and 239 with histological UIP. The 183 cases with asbestos exposure had higher rates of positive occupational history and histological UIP (31%) than the remaining 1535. Among the asbestos-exposed group, small numbers of asbestos bodies were found in histological specimens of 21 cases of histological UIP. PPs and asbestos bodies were more frequent in the 239 patients with histological UIP than in the remaining 1479 UIP-negative patients. Multivariate analysis showed that asbestos exposure, especially positivity for asbestos bodies, that does not meet the current criteria for asbestosis increases the risk of histological UIP (P < 0.0001). CONCLUSIONS: Asbestos exposure causes asbestosis and increases the incidence of histological UIP.

A Simple and Reliable Method for Intracorporeal Circular-Stapled Esophagojejunostomy Using a Hand-Sewn Over-and-Over Suture Technique in Laparoscopic Total Gastrectomy.

BACKGROUND: The controversy regarding laparoscopic total gastrectomy (LTG) is mainly due to the difficulty associated with esophagojejunostomy during this procedure. Although several techniques have so far been reported to overcome this issue,1 (-) 4 a reliable technique has not yet been established. We developed intracorporeal esophagojejunostomy using a circular stapler in LTG with a hand-sewn over-and-over suture technique, and have shown its favorable outcomes compared with those of conventional open surgery.5 This technique is presented in the video. METHODS: After transection of the esophagus, an over-and-over suture with a 2-0 monofilament is placed counterclockwise from the right to the left side of the cut end in an outside-to-inside direction, and then from the left to the right side in an inside-to-outside direction. After insertion of the anvil head into the esophagus, it was fixed by ligation of the thread. Finally, intracorporeal esophagojejunal anastomosis was performed using a circular stapler. RESULTS: In LTG, reconstruction using this method was performed for 23 consecutive patients with gastric cancer. There were no serious intraoperative complications or need for conversion to open surgery. Anastomotic leakage and stenosis occurred in one case each, respectively. The mean time for fixation of the anvil to the esophagus was 15 min for the last 12 consecutive patients. CONCLUSIONS: This method is simple and feasible, and the advantage of this technique is the elimination of the backhand stroke throughout the suturing procedure.

A Three-Step Method for Laparoscopic Mobilization of the Splenic Flexure.

BACKGROUND: Splenic flexure mobilization (SFM) is sometimes required for secure and tension-free anastomosis during laparoscopic colorectal surgery. Although several approaches have been used for laparoscopic SFM,1 it is still considered complicated and troublesome because of the lack of a standardized technique. We propose a three-step method for laparoscopic SFM, aimed at providing a simplified and standardized method, which is presented in the video. METHOD: First, the mesocolon of the transverse and descending colon is dissected from the retroperitoneal tissue using a medial approach. The appropriate plane for dissection can be recognized just beneath the inferior mesenteric vein, and the gauze should be placed in the dissected space. Second, the transverse colon and transverse mesocolon are detached from the pancreas and spleen by means of an anterior approach. The lesser sac is opened, and the attachment to the pancreas or spleen is cut using the inserted gauze as a landmark. Third, the lateral attachment of the descending colon to the left abdominal wall is dissected cranially or caudally. RESULTS: Using this method, we performed laparoscopic SFM for 13 patients with colorectal cancer with no conversion to another approach or to open surgery. No intraoperative complications were reported, including bleeding from the spleen and injury of the pancreas. The mean time for SFM was 55 min. CONCLUSIONS: We consider this three-step method as being useful, and it might help the standardization of laparoscopic SFM.

Surgical outcomes of intracorporeal circular-stapled esophagojejunostomy using modified over-and-over suture technique in laparoscopic total gastrectomy.

BACKGROUND: Esophagojejunostomy in laparoscopic total gastrectomy (LTG) is a technically demanding procedure. Although several methods have been reported to date, none is considered consistently reliable. We developed a simple method for intracorporeal circular-stapled esophagojejunostomy using a modified over-and-over suture technique. The surgical outcomes of our technique were evaluated in comparison with those of open total gastrectomy (OTG). METHODS: From April 2012 to August 2014, reconstruction using this method in LTG was performed for 21 consecutive patients with gastric cancer (LTG group). Their surgical outcomes were compared with those of 27 patients with gastric cancer who underwent OTG without splenectomy (OTG group) between January 2011 and April 2014. RESULTS: Estimated blood loss was significantly lower, and the postoperative hospital stay was significantly shorter in the LTG group than in the OTG group. The operating time and the number of harvested lymph nodes were similar between the two groups. The incidence of overall complications did not differ significantly between the two groups. Anastomotic leakage developed in one of the 21 patients in the LTG group and in two of the 27 patients in the OTG group. Anastomotic stenosis was observed in one patient in the LTG group. CONCLUSIONS: We consider this method as simple and feasible for most laparoscopic surgeons with basic laparoscopic suturing skills. This method might help LTG to become an accepted standard surgical option for treatment of patients with gastric cancer.

Cranially approached radical lymph node dissection around the middle colic vessels in laparoscopic colon cancer surgery.

PURPOSE: Laparoscopic lymph node (LN) dissection around the middle colic vessels is technically demanding, thus raising controversy regarding the role of laparoscopic surgery for transverse colon cancer. We herein describe a cranial approach method to perform radical LN dissection around the middle colic vessels. The key characteristic of this approach is early division of middle colic vessels prior to mobilization of the colon. METHODS: From April 2010 to September 2013, 27 patients with colon cancer received laparoscopic LN dissection around the middle colic vessels using this cranial approach. Their surgical and short-term outcomes were reviewed. RESULTS: The mean number of harvested LNs was 29 (range, 6-50). The mean operative time and intraoperative blood loss were 274 min (range, 160-362 min) and 42 mL (range, 3-247 mL), respectively. There were no serious intraoperative complications or conversions to open surgery. There were two patients with stage 0, 7 with stage I, 12 with stage II, and 6 with stage III. No recurrent case was observed with a median follow-up period of 30 months (range, 9-48 months). CONCLUSIONS: We consider this approach feasible and useful for radical LN dissection around the middle colic vessels during laparoscopic colon cancer surgery.

[A case of Lemierre's syndrome with septic pulmonary embolisms].

A 41-year-old-man with sore throat and fever visited a nearby clinic. He was given antibiotics, but on disease day 11, the left side of his neck had swollen. Because chest CT on disease day 16 showed bilateral multiple pulmonary nodules, he was admitted to our hospital. He had septic pulmonary embolisms and thrombophlebitis of the left internal jugular vein, and Fusobacterium necrophorum was isolated from the blood and neck pus culture, and we diagnosed him as having Lemierre's syndrome. We administered piperacillin/ tazobactam and heparin, and his symptoms improved thereafter. Lemierre's syndrome is relatively rare but is increasing in recent years. We report herein this case and compare reported cases in Japan with those from overseas.

Prognostic factors of 634 HIV-negative patients with Mycobacterium avium complex lung disease.

RATIONALE: The prognostic factors of Mycobacterium avium complex lung disease (MAC-LD) are not clearly defined. OBJECTIVES: To assess the prognostic factors of all-cause and MAC-specific mortality in patients with MAC-LD, especially in accordance with radiographic features, first-line treatment, and host predisposition. METHODS: Medical records of 634 HIV-negative patients with MAC-LD treated at our institution in Saitama, Japan were retrospectively analyzed. MEASUREMENTS AND MAIN RESULTS: Patients' mean age was 68.9 years, and median follow-up period was 4.7 years. Radiographic features included nodular/bronchiectatic (NB) disease: 482 patients (76.0%); fibrocavitary (FC) disease: 105 patients (16.6%); FC+NB disease: 30 patients (4.7%); and other types: 17 patients (3.0%). First-line treatments were observation or one drug: 479 patients (75.6%); 2 to 5 drugs: 131 patients (20.7%); and unknown: 24 patients (3.8%). A multivariate Cox proportional hazard model showed male sex, older age, presence of systemic and/or respiratory comorbidity, non-NB radiographic features, body mass index (BMI) less than 18.5 kg/m(2), anemia, hypoalbuminemia, and erythrocyte sedimentation rate greater than or equal to 50 mm/h to be negative prognostic factors for all-cause mortality, and FC or FC+NB radiographic features, BMI less than 18.5 kg/m(2), anemia, and C-reactive protein greater than or equal to 1.0 mg/dl to be negative prognostic factors for MAC-specific mortality. CONCLUSIONS: The first-line treatment regimen was not associated with all-cause mortality. FC or FC+NB disease, BMI less than 18.5 kg/m(2), and anemia were negative prognostic factors for both all-cause and MAC-specific mortality.

Magnetic resonance imaging can detect thoracic inflammation due to familial Mediterranean fever.

A 32-year-old man presented to our hospital complaining of periodic fever and unilateral chest pain. We suspected that he had familial Mediterranean fever because of his symptoms. Magnetic resonance imaging (MRI) showed an increased intensity within the anterior chest wall, which was consistent with the site of his pain. Genomic analysis showed the patient to be heterozygous for the E148Q/M694I mutation in the MEFV gene, and we diagnosed familial Mediterranean fever. The ability of MRI to detect inflammatory changes could provide useful additional information for evaluating thoracic symptoms in FMF patients, and the detection of inflammatory changes using MRI may aid in early diagnosis, thus contributing to early and adequate treatment.

Regioselective 1,4-trifluoromethylation of α,ß-unsaturated ketones via a S-(trifluoromethyl)diphenylsulfonium salts/copper system.

Regioselective conjugate 1,4-trifluoromethylation of α,ß-unsaturated ketones by the use of shelf-stable electrophilic trifluoromethylating reagents, S-(trifluoromethyl)diphenylsulfonium salts and copper under mild conditions is described. A wide range of acyclic aryl-aryl-enones and aryl-alkyl-enones were converted into ß-trifluoromethylated ketones in low to moderate yields.

Airway dimensions and pulmonary function in chronic obstructive pulmonary disease and bronchial asthma.

BACKGROUND AND OBJECTIVE: COPD and bronchial asthma are chronic airway diseases with a different pathogenesis. Comparisons of differences in airway calibre by bronchial generation between these diseases and their importance to pulmonary function have not been fully studied. We investigated airway calibre and wall thickness in relation to pulmonary function in patients with asthma, COPD, asthma plus emphysema and normal subjects using CT. METHODS: Sixty-three asthmatic patients, 46 COPD, 23 patients with asthma plus emphysema and 61 control subjects were studied cross-sectionally. We used a software with curved multiplanar reconstruction to measure airway dimensions from 3rd- to 6th-generation bronchi of the right lower posterior bronchus. RESULTS: Patients with COPD had increased wall thickness, but the airway was not narrow from the 3rd-(subsegmental) to 6th-generation bronchi. Mean bronchial inner diameter (Di) of 3rd- to 6th-generation bronchi in patients with asthma or asthma plus emphysema was smaller than that of COPD patients and normal subjects. Airway luminal area (Ai) of 5th-generation bronchi most closely correlated with pulmonary function in patients with stable asthma. Although Di was similar in patients with asthma and asthma plus emphysema, the Ai of 6th-generation bronchi correlated significantly with pulmonary function in patients with asthma plus emphysema. CONCLUSIONS: Airway calibre in asthma may be smaller than in COPD. Airflow limitations correlated more closely with peripheral Ai in patients with asthma plus emphysema than in patients with asthma alone.

Desquamative interstitial pneumonia may progress to lung fibrosis as characterized radiologically.

BACKGROUND AND OBJECTIVE: In some patients, desquamative interstitial pneumonia may progress to lung fibrosis. The aim of this study was to assess the long-term radiological follow-up results in patients with desquamative interstitial pneumonia. METHODS: Among 75 patients suspected of having desquamative interstitial pneumonia, 31 who fulfilled the criteria were included in this study. Clinical characteristics at presentation, responses to treatment and long-term follow-up were evaluated. RESULTS: The 31 patients were predominantly males (94%), and the mean age was 55 years; 93% (28/30) had a history of smoking. The clinical findings included high serum levels of lactate dehydrogenase and immunoglobulin G. Bronchoalveolar lavage (26 patients, 84% of cases) frequently showed an increased percentage of eosinophils (mean 17%). Computed tomography (CT) or high resolution (HR) CT at presentation showed ground glass opacities and/or consolidation in all patients, with one third of patients also showing thin-walled cysts within the ground glass opacities. There was no honeycombing on CT or HRCT scans at presentation. Corticosteroid therapy was effective early in the course of the disease; long-term follow-up (mean 99 months) of 31 patients showed only one death due to progression of the disease, but long-term follow-up of 14 patients (mean 125 months) by HRCT showed the development of new thin-walled cysts and honeycombing in five and lung cancer in four patients, respectively. CONCLUSIONS: In a proportion of patients, desquamative interstitial pneumonia may progress to lung fibrosis with honeycombing on HRCT, despite therapy.

[Clinical analysis of mycobacteriosis patients with pneumothorax].

BACKGROUND: Secondary pneumothorax caused by mycobacteriosis is rare. The frequency of incidence of pneumothorax in tuberculosis patients is reported to be only 1.5%, and that in nontuberculous mycobacteriosis patients may be very low. It is important to detect mycobacteriosis at an earlier stage in patients hospitalized for pneumothorax, in general wards so that nosocomial infections such as tuberculosis can be prevented. OBJECTIVE: Chart review of mycobacteriosis patients with secondary pneumothorax admitted to the isolation ward, and that of the mycobacteriosis patients with pneumothorax admitted in the general wards of our hospital. METHODS: We reviewed records of 555 mycobacteriosis patients admitted to the isolation ward of our hospital from January 2006 to December 2008. We analyzed the reasons for admission and cause, treatment, and outcome of pneumothorax. RESULTS: Of the 555 mycobacteriosis patients, 11 (2.0%) had complications of pneumothorax. Among these 11 patients, 9 had tuberculosis, and 2 had nontuberculous mycobacteriosis. Of the 11, 5 were discharged, but 6 (54.5%) died during hospitalization, while among the remaining 544 mycobacteriosis patients without pneumothorax, 49 (9%) died during hospitalization. The hospital death rate of mycobacteriosis patients with pneumothorax was significantly higher than that of mycobacteriosis patients without pneumothorax (p < 0.0001). Among the 9 tuberculosis patients, 4 in whom pneumothorax was caused by rupturing of bullae showed improvement except one patient, but 5 in whom pneumothorax was caused by tuberculosis died. Excluding the 555 patients admitted to the isolation ward, 388 pneumothorax patients were admitted to the general ward during the same period, among which 3 (0.8%) had mycobacteriosis. CONCLUSION: Tuberculosis-induced pneumothorax has a poor prognosis because the occurrence of tuberculosis impairs the mechanism of recovery from pneumothorax.

Comparison of high-dose salmeterol/fluticasone and moderate-dose salmeterol/fluticasone plus low-dose mometasone in patients with severe persistent asthma.

BACKGROUND AND OBJECTIVE: The effects of adding a second inhaled corticosteroid with a different particle size, compared with using an increased dose of a single inhaled corticosteroid, were assessed in patients with persistent asthma. METHODS: This was an open-label study of Japanese asthma patients over 20 years of age. After a 1-month run-in period, 36 patients with inadequate control while using salmeterol/fluticasone propionate 50/250 µg (SFC50/250) bd, were randomized to receive SFC50/500 bd or SFC50/250 plus mometasone 100 µg bd (SFC50/250/MF100) for 2 months. RESULTS: Both treatments resulted in improvements in morning and evening PEF. There were no significant changes in FEV(1) , maximum mid-expiratory flow, maximum expiratory flow rate at 50%, maximum expiratory flow rate at 25% or exhaled NO (FENO) in the SFC50/500 group. On the other hand, there were significant improvements in FEV(1) % (+12.2%, P = 0.0142), %maximum mid-expiratory flow (+28.9%, P = 0.0181), %MEF50 (+32.4%, P = 0.0206) and %MEF25 (+30.3%, P = 0.0113) in the SFC50/250/MF100 group. The changes in FENO (-23.2% (P = 0.0157) in the SFC50/250/MF100 group and -14.5% (not significant) in the SFC50/500 group) did not differ significantly between the groups. CONCLUSIONS: In patients with severe persistent asthma, addition of low-dose mometasone to SFC50/250 improved spirometric parameters, FENO and PEF, while an increase in dose from SFC50/250 to SFC50/ 500 only improved PEF.

[Legionella pneumonia in a patient with positive culture results of Legionella pneumophila serotype 1 from bronchoalveolar lavage fluid but negative urinary antigen test results].

A 39-year-old man presented to a local physician complaining of fever, headache without cough or sputum. Abnormal shadows were found on chest X-ray films. Pneumonia was diagnosed and he was referred to our hospital, where chest computed tomography showed bilateral, multifocal, and patchy ground-glass opacities. Neither the urinary antigen test for Streptococcus pneumoniae nor that for Legionella was positive. Because he had visited a public spa several days before developing the fever and headache, and because hypophosphatemia was identified, we then suspected Legionella pneumonia. Bronchoalveolar lavage fluid yielded positive culture of Legionella pneumophila serotype 1. The Legionella urinary antigen is known to detect Legionella pneumophila serotype 1 infection; however, sensitivity and specificity of the test are 60-95% and > 99%, but care should be taken when urinary antigen test results are negative in suspected cases of Legionella pneumophila serotype 1 pneumonia. In the present case, bronchoalveolar lavage fluid was a useful method for diagnosing Legionella pneumonia.

[A case of organizing pneumonia which recurred 51 months after radiotherapy following breast-conserving surgery].

A 54-year-old woman who had undergone breast-conserving surgery followed by irradiation presented to a local physician after developing a cough and low-grade fever 9 months after radiation therapy. She was given a diagnosis of pneumonia and antibiotics were administered, but since she did not improve, she was transferred to our hospital. We performed lung biopsy via thoracoscopy and diagnosed organizing pneumonia based on pathological findings. Steroid administration based on her chest X-ray findings, improved her condition. After discharge, her steroid dose was tapered on an outpatient basis, but she suffered relapse of her organizing pneumonia three times. The prednisolone dose at relapse was 10 mg/day at 20 months, 7.5 mg/day at 36 months, and 7 mg/day at 51 months after radiation therapy, respectively. Organizing pneumonia that develops after irradiation following breast-conserving surgery has been known to occasionally relapse, and to the best of our knowledge the final relapse reported here, 51 months after radiation therapy is the longest relapse reported.

[Type A influenza pneumonia with diffuse alveolar damage diagnosed by increased antibody titers and immunohistochemical staining].

A 58-year-old man presented to a local physician with cough, fever, myalgia and dyspnea. His chest X-ray film showed abnormal shadows and therefore he was admitted to our hospital. Chest computed tomography showed bilateral ground-glass opacities and bilateral consolidation. We suspected influenza pneumonia, but the results of both an influenza rapid antigen test and reverse transcriptase-polymerase chain reaction test for novel influenza (H1N1 2009) were negative. Transbronchial lung biopsy showed diffuse alveolar damage patterns. We diagnosed acute interstitial pneumonia and initiated corticosteroid therapy. Moreover, because influenza pneumonia could not be excluded according to his clinical picture, oseltamivir was administered. His condition improved and he was discharged. After discharge, the levels of antibody titers for influenza A virus significantly increased. We therefore re-evaluated his transbronchial lung biopsy specimen and found that immunohistochemical staining was positive for influenza A antigen in his bronchial and bronchiolar cells. We re-diagnosed his condition as influenza pneumonia. The possibility that influenza pneumonia may present in cases originally diagnosed as acute interstitial pneumonia must be considered.

[Eight cases of idiopathic pulmonary alveolar proteinosis followed up for more than 4 years].

BACKGROUND: Few reports exist regarding the long-term clinical course of idiopathic pulmonary alveolar proteinosis. PURPOSE AND METHODS: We retrospectively studied the clinical courses of 8 patients. The patients were 4 men and 4 women aged 48.4 +/- 14.0 years (mean +/- SD) with idiopathic pulmonary alveolar proteinosis followed up for a minimum of more than 4 years. Mean follow-up was 13 years and 6 months (4-22 years and 9 months). RESULTS: There were 15 instances of whole-lung lavage and/or bronchoalveolar lavage in 7 patients, and lavage was effective 40% of cases. Spontaneous improvement occurred 16 times and exacerbation occurred 7 times in 8 patients. On chest X-ray films, the shadows disappeared in 5 of 8 (62.5%) patients, and in 4 of 5 patients, shadows disappeared 5 or more years after diagnosis of pulmonary alveolar proteinosis. Pulmonary shadows have not disappeared in the remaining 3 patients at the time of writing but have shown improvement compared with first presentation. There were no deaths. CONCLUSION: As indicated in previous reports, the long-term outcome of idiopathic pulmonary alveolar proteinosis appears to be good.

[A case of follicular bronchiolitis in which progressive bronchiectasis developed over 7 years].

A 53-year-old man presented to our hospital with cough in August 2004. Chest computed tomography showed an anterior mediastinal tumor, centrilobular nodules and mild bronchiectasis. Centrilobular nodules were improved by the administration of clarithromycin, and we resected an anterior mediastinal tumor (thymoma). Partial lung resection was also performed, and a diagnosis of follicular bronchiolitis was established. The number of centrilobular nodules increased after cessation of the clarithromycin, and its administration was reinitiated; however, the patient's bronchiectasis and airway obstruction worsened. Steroid administration was begun in January 2010; thereafter, pulmonary function, bronchial wall thickness, cough and shortness of breath improved. Since April 2004, the patient has experienced 12 episodes of airway infection. Careful attention should be paid to recurrent airway infection, progressive bronchiectasis and airway obstruction in patients with follicular bronchiectasis.