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Imatinib is the standard treatment for unresectable and metastatic GIST. In the late stages, patients undergoing imatinib show drug resistance. Surgical intervention has been occasionally performed for resistant lesions. However, the clinical significance of such intervention remains unclear. Between 2006 and 2015, 37 patients were diagnosed with imatinib-resistant GISTs. We performed surgical intervention only for localized resistant lesions. We retrospectively investigated the background characteristics, data on surgical intervention and subsequent treatment, progression-free survival (PFS), and overall survival (OS). Eighteen patients diagnosed with localized resistance received surgical intervention (S-group) and 19 patients diagnosed with generalized resistance were received other TKIs (M-group). In S-group, no serious complications occurred, and all patients restarted imatinib after resection. The median PFS was 14.5 months. Five patients underwent surgical intervention multiple times followed by the continuation of imatinib, and the median duration of imatinib continuation was 22.2 months. Second-line TKIs were administered to 93% of the patients and the dose-intensity and outcome were similar in both groups. The median OS was 47.2 months after surgery. Surgical intervention could be performed safely and therefore could be followed by the continuation of TKI therapy. Surgical intervention based on the appropriate criteria of resistance might thus be useful for imatinib-resistant GISTs.

Surgery-induced factors such as postoperative infectious complications (PICs) and intraoperative blood loss (IBL) have a negative impact on the survival of patients undergoing surgery for gastric cancer. A recent study showed that neoadjuvant chemotherapy (NAC) could reduce the negative impact of PICs; hence, we conducted the present study to investigate if NAC can also reduce the negative prognostic impact of IBL. We reviewed 115 gastric cancer patients treated with NAC and radical gastrectomy. The cut-off for IBL predicting the long-term survival was assessed by a receiver operating characteristic curve. The Cox proportional hazard model was used to evaluate the association between patient characteristics including IBL, overall survival, and disease-free survival. The cut-off for IBL was set at 990 ml. Twenty-six patients had excessive IBL exceeding 990 ml (22.6%) and PICs developed in 33 patients (28.7%). The body mass index, IBL, ypT, and ypN were significant independent prognostic predictors, but PICs were not. NAC did not decrease the risk induced by excessive IBL. The prophylactic effect of NAC on surgery-induced risk was inconsistent.

T1 gastric cancer is treated by endoscopic submucosal dissection (ESD) or surgery, considering the risk of lymph node metastasis. Additional gastrectomy is necessary when the pathological specimens after ESD show some risk of lymph node metastasis. Preoperative computed tomography (CT) after ESD sometimes reveals enlarged lymph nodes, which should prompt surgeons to select D2 over D1/D1+. However, whether or not CT after ESD is reliable remains unclear. Patients who underwent radical gastrectomy for clinical T1 between April 2015 and June 2019 were enrolled. The patients were classified into those who underwent CT after ESD (group A) and those who underwent CT before primary surgery or ESD (group B). The accuracy of the nodal diagnosis was compared between groups. A total of 650 patients (group A; 81, group B; 569) were examined. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value (group A vs. group B) were 77.8% vs. 84.2%, 0.0% vs. 15.9%, 84.0% vs. 95.7%, 0.0% vs. 38.2%, and 91.3% vs. 87.1%, respectively. The false-positive rate was 100% in group A and 61.8% in group B (p = 0.011). A nodal diagnosis by CT is unreliable for patients who need additional gastrectomy after ESD.

To investigate the efficacy and safety of Daikenchuto (DKT) for colorectal cancer patients undergoing surgery with the potential risk of postoperative ileus (POI). Colorectal cancer patients with abdominal pain and distention, scheduled for surgery, were randomly assigned to a DKT group or a control group. Patients assigned to the DKT group were given 15 g of DKT per day during the perioperative period. We then compared the perioperative gastrointestinal symptoms between the two groups. The aim for a sample size of 30 patients per group was not reached in time, so we conducted an analysis on 16 patients in each group. The visual Analogue Scale scores for abdominal pain and distention were similar in the two groups. The number of bowel movements per day on postoperative days (PODs) 1, 2, and 6 were significantly lower in the DKT group. The incidence of a sensation of incomplete bowel evacuation on PODs 3 and 28 was also significantly lower in the DKT group. There were no adverse events thought to be related to DKT. DKT could potentially inhibit diarrhea and reduce the number of bowel movements per day and the sensation of incomplete bowel evacuation after colorectal surgery. Thus, the perioperative use of DKT may be safe for colorectal cancer patients with abdominal pain and distention, who undergo surgery.

Endoscopic submucosal dissection is recommended for early gastric cancer with a low risk of lymph node metastasis. When the pathological findings do not meet the curative criteria; then, an additional gastrectomy with lymph node dissection is recommended. However, most cases have neither lymph node metastasis nor a local residual tumor during an additional surgery.This was a single-institutional retrospective cohort study, analyzing 200 patients who underwent an additional gastrectomy after non-curative endoscopic submucosal dissection from January 2005 to October 2015. We reviewed the patients' clinicopathological data and evaluated the predictors for the presence of a residual tumor.Histopathology revealed lymph node metastasis in 15 patients (7.5 %) and a local residual tumor in 23 (11.5 %). A multivariable analysis revealed macroscopic findings (flat/elevated type) (p = 0.011, odds ratio = 4.63), lymphatic invasion (p 0.0001, odds ratio = 14.2), and vascular invasion (p = 0.04, odds ratio = 4.00) to be predictors for lymph node metastasis. A positive vertical margin (p = 0.0027, odds ratio = 3.26) and horizontal margin (p = 0.0008, odds ratio = 5.74) were predictors for a local residual tumor. All cases with lymph node metastasis had lymphovascular invasion with at least one other non-curative factor.The risk of a residual tumor can, therefore, be estimated based on the histopathology of endoscopic submucosal dissection samples. Lymphovascular invasion appears to be a pivotal predictor of lymph node metastasis.

Rectal gastrointestinal stromal tumors (GISTs) are rare. Accordingly, their clinical features are not well-documented and optimal treatment has not been established. The objective of this study is to clarify the rates and patterns of recurrence after surgical resection of rectal GISTs, with a focus on outcomes and therapeutic modalities. The registry was designed to collect data on rectal GISTs recorded between January, 2003 and December, 2007 at 40 participating institutions of the Kinki GIST Study Group. The principal variables were the rates and patterns of recurrence of rectal GISTs. Other study variables were age, sex, tumor size, mitotic count, distance from the anal verge, tumor location, surgical procedures, surgical margins, and recurrence-free survival. Twenty-four cases were registered, 11 (45.8%) of which were classified as high-risk by the modified NIH criteria. Locoregional recurrence (7/23, 30.4%) was the predominant recurrence pattern after curative resection, with rates that did not differ after local excision (33.3%; 3/9) vs. extended resection (28.6%; 4/14). The recurrence rates were high (25.0%) even for patients with low-risk disease. There was only one case of recurrence among patients who received perioperative treatment with imatinib. Rectal GISTs showed high rates of local recurrence regardless of the surgical procedure. Perioperative treatment with imatinib may improve outcomes.

Melanoma with metastasis to the common bile duct is relatively rare. This report presents the case of a 56-year-old Japanese male that showed an abnormal laboratory profile 18 months after resection of a skin melanoma occurring on the left fifth finger. The cytology of bile obtained by endoscopic retrograde cholangiopancreatography yielded a diagnosis of melanoma with metastasis to the common bile duct. Surgery revealed melanoma within the distal common bile duct. There were no other secondary metastases in the abdomen and a radical pancreatoduodenectomy was performed. The patient survived for 13 months without any signs of recurrence and died of progressive systemic metastatic melanoma 34 months after surgery. Therefore, radical surgical resection appears to be effective for the prolongation of survival in cases of melanoma with metastasis to the common bile duct.

The objective of this study was to investigate the clinicopathological features and postoperative survival of primary colorectal signet-ring cell carcinoma.Nineteen patients with primary colorectal signet-ring cell carcinoma were identified from a database of 5884 surgical patients with colorectal cancers treated surgically at Osaka University Hospital and affiliated hospitals between 1993 and 2007. The clinicopathological data of those patients were compared with those of 5792 patients with non-signet-ring cell colorectal carcinoma (5417 with well or moderately differentiated adenocarcinoma and 375 with poorly differentiated adenocarcinoma or mucinous carcinoma).All patients showed a tumor depth of over T3. Lymph node involvement occurred in 14 patients. Seven of 19 patients presented with distant metastasis at the time of diagnosis. The overall 5-year survival rate in primary signet-ring cell carcinoma was significantly lower at 24.1%, in comparison to 77.5% in well or moderately differentiated adenocarcinoma and 57.7% in poorly differentiated adenocarcinoma or mucinous carcinoma. Likewise, the postoperative survival in Stage III was also significantly worse. On the other hand, no significant difference was observed in Stage II or IV.The most important feature of primary colorectal signet-ring cell carcinoma is the advanced stage at the time of diagnosis. In addition, the postoperative survival is worse than for other types of colorectal cancer.

A fibrin-coated collagen fleece (TachoComb, Nycomed, Denmark) is a powerful topical hemostatic agent, which has been aggressively used in conventional open surgery with a favorable clinical outcome. However, the use of TachoComb in laparoscopic surgery has not yet gained wide clinical acceptance, because a simple and well-functioning application system is not available. The authors have newly developed a quick, simple, and effective laparoscopic TachoComb application technique: housing a small strip of TachoComb in a rubber tube, then conveying it into the peritoneal cavity, and applying it using standard laparoscopic forceps. The repeated application of TachoComb strips is feasible and of practical value especially in laparoscopic surgery, since a small TachoComb never compromises either the application procedure or laparoscopic visualization.

To define the role of surgery for metastatic/recurrent lesions after resection of primary gastrointestinal stromal tumors (GISTs). Based on data obtained from the Kinki GIST registry, patients with recurrence or metastasis were divided into a surgical treatment group (ST group), comprised those treated with surgery in addition to tyrosine kinase inhibitor (TKI) therapy; and a drug treatment group (DT group), comprised those treated with TKI therapy alone. We compared the baseline characteristics and survival outcomes of the groups. Metastasis or recurrence developed in 93 of the 737 patients with GISTs treated between 2003 and 2007, 50 (53.8 %) of whom were assigned to the ST group and 43 (46.2 %) to the DT group. In the ST group, the 5-year overall survival rate was significantly higher for patients who underwent R0/R1 resection than for those who underwent R2 resection (82.2 vs. 47.0 %, p = 0.018). Survival time after recurrence was correlated with the duration of total TKI therapy in both the ST and DT groups (r = 0.766 and r = 0.932, respectively, p

To investigate the outcomes of a combined treatment regimen comprising primary surgery and tyrosine kinase inhibitor (TKI) therapy for synchronous metastatic gastrointestinal stromal tumors (GIST).We analyzed retrospectively 14 cases of synchronous metastatic GIST from the Kinki GIST registry between 2003 and 2007.The primary tumor was located in the stomach, small intestine, and rectum in seven, six, and one patients, respectively. Metastatic tumors developed in the liver, peritoneum, other sites, and multiple organs in three, six, two, and three patients, respectively. The R0 resection rate was 42.9 % and the 5-year overall survival rate was 69.3 %. There was no significant difference in the 5-year overall survival rate between patients who underwent R0/R1 and those who underwent R2 resection (71.4 vs. 68.6 %). There was a strong correlation between survival time from diagnosis and the duration of imatinib therapy (Pearson's correlation coefficient, 0.86; p 0.001).Although the role of surgery in the treatment of synchronous metastatic GIST is still unclear, primary surgery as the sole frontline treatment may not have a survival benefit: Continuous TKI therapy is more important for prolonging survival.

We developed a technique of jejunal pouch interposition with a fundic-like jejunal plication (JPI-FP) for reconstruction after total gastrectomy (TG) for gastric cancer. The aim of this study was to investigate the advantages of JPI-FP over Roux-en-Y reconstruction (R-Y).Twenty-two patients who had undergone TG more than 1 year earlier were classified into two groups according to the method of reconstruction used: Group A (n = 7) underwent R-Y, and group B (n = 15) underwent JPI-FP. Group B was subdivided into two groups to examine the usefulness of additional pylorus preservation: group B1 (n = 8), pylorus (-) and group B2 (n = 7), pylorus (+).Food intake and body weight were significantly higher in group B than in group A (P0.05). Reflux esophagitis was diagnosed in two of the group A patients, but in none of the group B patients. Excessive esophageal bile exposure, determined as the fraction time of esophageal bilirubin absorbance over 0.1450%, was significantly higher in group A than in group B (P0.05). There was no significant difference in bile exposure in the jejunal pouch between groups B1 and B2.JPI-FP is a superior method of reconstruction after TG to prevent excessive esophageal bile reflux and from a nutritional aspect. The advantage of pylorus preservation remains unconfirmed.

We describe a unique case of intra-abdominal textiloma (granuloma due to a retained foreign body), which mimicked a gastric tumor on preoperative imaging studies. A 78-year-old asymptomatic patient with a past history of a gastrectomy was referred for evaluation of an intra-abdominal mass lesion, which was incidentally observed on a computed tomography (CT) scan. Repeated CT with a higher resolution demonstrated a 5-cm heterogeneously enhanced mass with a distinct feeding artery. These findings were all compatible with a tumorous lesion originating in the gastric remnant, most likely gastric gastrointestinal stromal tumor. A diagnosis of textiloma was immediately made during surgery, and it was confirmed pathologically postoperatively. The feeding artery that appeared on CT images, which was a major reason for the false diagnosis, was considered to have resulted from a slow but continuous inflammation reaction around the retained surgical sponge. Surgeons should therefore always take the possibility of textilomas into consideration even with typical tumorous characteristics on preoperative imaging studies, especially in patients with a history of prior abdominal surgery.

Collagen and fibrin are known to have potential use as a local drug-delivery system. This experimental study was designed to evaluate whether a fibrinogen-based collagen (FBC) fleece, coated with thrombin and aprotinin, can be used as an antibiotic delivery system.In an in vitro study, gentamicin, fosfomycin, ampicillin, ciprofloxacin and dibekacin were absorbed by the FBC, Kirby-Bauer disks (KBDs), and expanded polytetrafluoroethylene. After washing with saline or phosphate buffer saline (PBS) 3 times for 6, 12 and 24 h, each sample was analyzed for antibiotic retention. In an in vivo study, we implanted the FBC onto mouse livers and dripped gentamicin and ciprofloxacin onto the FBC. The FBCs were subsequently collected and analyzed for their antibiotic activities.After irrigation with saline, each antibiotic showed different activities. After PBS washing, the FBC impregnated with each antibiotic had higher activity than the KBDs, and inhibited the bacterial growth by 60-80 % compared to the control. Gentamicin dripped onto the FBC could inhibit bacterial growth after 48 h in vivo without affecting the hemostatic properties of the FBC. However, the FBC treated with ciprofloxacin exhibited antibacterial activity for only 3 h.Some bases, including FBC, can retain antibacterial activities dependent on the ingredients of the base and the type of antibiotic. Gentamicin, but not ciprofloxacin, was retained in the FBC in vivo. These results suggest that absorbent FBC might be useful not only as hemostatic material, but also as a local drug-delivery system.

Acute pancreatitis occurring in an aberrant pancreas (acute aberrant pancreatitis) is a rare clinical condition. A 67-year-old male was referred to the emergency department complaining of severe epigastralgia. He was evaluated by computed tomography, and the findings suggested jejunal penetration into the mesentery and abscess formation. We performed emergency surgery and found a mass located in the jejunal mesentery. Intraoperatively, we diagnosed it to be a malignant tumor complicated by penetration, and we performed a partial resection of the jejunum to remove the mass. Based on the pathological results, it was evident that this was a case of acute aberrant pancreatitis occurring on a background of chronic pancreatitis. The patient had an uneventful postoperative course. This report is the first presentation describing the possible mechanism that contributes to the process of infected pancreatic necrosis in an aberrant pancreas.

The aim of this study was to evaluate the risk factors and outcome of patients with hyperbilirubinemia after surgery for generalized peritonitis.We retrospectively analyzed data from 229 patients with generalized peritonitis caused by gastrointestinal (GI) perforations.Postoperative hyperbilirubinemia defined as a value ofor =5 mg/dl, within 1 month, developed in 39 patients. Postoperative hyperbilirubinemia was related to age ( P = 0.0102), poor nutritional status ( P = 0.0388), decreased base excess ( P = 0.0037), delay until surgery ( P = 0.0276), preoperative serum bilirubin ( P = 0.0321) and postoperative persistent infection ( P0.0001). Higher mortality was seen in patients with hyperbilirubinemia (59%) than in those without hyperbilirubinemia (4%). The patients with hyperbilirubinemia who survived had decreased serum bilirubin levels after 3-5 postoperative days whereas a continuous increase was seen in the patients who ultimately died. Preoperative shock ( P = 0.0003), a decreased preoperative platelet count ( P = 0.0152), postoperative infection ( P = 0.0050), and postoperative hyperbilirubinemia ( P0.0001) were risk factors for overall mortality.These results indicate that postoperative hyperbilirubinemia in patients with GI perforation is related to persistent postoperative infection and associated with poor prognosis.