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Purpose Iatrogenic gallbladder perforation frequently occurs during laparoscopic cholecystectomy and may increase the risk of infectious complications. The effectiveness of postoperative antibiotics and drainage in preventing infections remain unclear. The study aimed to investigate the clinical outcomes of patients with Iatrogenic gallbladder perforation during laparoscopic cholecystectomy in relation to these treatments.Methods One hundred twenty-one consecutive patients with Iatrogenic gallbladder perforation during laparoscopic cholecystectomy were enrolled. Surgeons chose the treatments for Iatrogenic gallbladder perforation: antibiotics (n = 48), drainage (n = 39), and no treatment (n = 34). Infectious complications were classified into wound infections, intra-abdominal abscesses, distant infections, and infections with unknown origin.Results The drainage group showed a nonsignificantly higher frequency of overall infectious complications than the other two groups (antibiotics vs. drainage vs. no-treatment = 14.6% vs. 23.1% vs. 11.8%, P = 0.31). The infection-positive group (n = 20) had a higher frequency of diabetes mellitus (positive vs. negative group = 52.6% vs. 17.7%, P = 0.0009) and lower preoperative albumin (3.8 vs. 4.1 g/dL, P = 0.0081) than the infection-negatve group. Multivariate analysis showed that a lower preoperative albumin (OR 4.90, 95% CI 1.20–20.0, P = 0.027) and the presence of diabetes mellitus (OR 5.49, 95% CI 1.62–18.6, P = 0.0063) were independent factors of overall infectious complications.Conclusions Additional treatments such as postoperative antibiotics and drainage may be unnecessary to prevent infectious complications in patients with Iatrogenic gallbladder perforation during laparoscopic cholecystectomy. diabetes mellitus and malnutrition were associated with postoperative infections. These findings should be validated in larger independent samples.

We have found that the etherification of silyl-protected secondary alcohols proceeds smoothly in the presence of strontium metal using silyl chloride instead of the expensive, yet more reactive, and commonly used silyl triflate. The reaction occurred almost completely with various alcohols.

PDF file - 8K, Gene promoter hypermethylation in GIST samples.

PDF file - 5K, Logistic regression analysis for the association between metastasis and LINE-1 methylation in high-risk category GIST patients.

PDF file - 364K, Reproducibility of bisulfite pyrosequencing analysis.

Purpose: Gastrointestinal stromal tumors (GIST) are the most important mesenchymal tumors of the gastrointestinal tract. The vast majority of GISTs exhibit activating mutations of KIT or PDGFRA, but epigenetic alteration of GISTs is largely unknown. In this study, we aimed to clarify the involvement of DNA methylation in GIST malignancy.Experimental Design: A total of 106 GIST specimens were studied. Levels of LINE-1 methylation were analyzed using bisulfite pyrosequencing. In addition, methylation of three other repetitive sequences (Alu Yb8, Satellite-α, and NBL2) was similarly analyzed, and CpG island hypermethylation was analyzed using MethyLight. Array-based comparative genomic hybridization (array CGH) was carried out in 25 GIST specimens.Results: LINE-1 hypomethylation was significantly correlated with risk, and high-risk GISTs exhibited significantly lower levels of LINE-1 methylation than low-risk (61.3% versus 53.2%; P = 0.001) or intermediate-risk GISTs (60.8% versus 53.2%; P = 0.002). Hypomethylation of Satellite-α and NBL2 was also observed in high-risk GISTs. By contrast, promoter hypermethylation was relatively infrequent (CDH1, 11.2%; MLH1, 9.8%; SFRP1, 1.2%; SFRP2, 11.0%; CHFR, 9.8%; APC, 6.1%; CDKN2A, 0%; RASSF1A, 0%; RASSF2, 0%) and did not correlate with LINE-1 methylation or risk. Array CGH analysis revealed a significant correlation between LINE-1 hypomethylation and chromosomal aberrations.Conclusions: Our data suggest that LINE-1 hypomethylation correlates significantly with the aggressiveness of GISTs and that LINE-1 methylation could be a useful marker for risk assessment. Hypomethylation may increase the malignant potential of GISTs by inducing accumulation of chromosomal aberrations. Clin Cancer Res; 16(21); 5114–23. ©2010 AACR.

PDF file - 507K, Chromosomal aberrations and their frequencies determined through array CGH analysis.

XLS file - 23K, GO analysis of differentially expressed genes in GISTs with and without miR-196a overexpression

XLS file - 28K, Correlation between miR-196a expression and the GIST risk category in different organs

XLS file - 196K, Genes upregulated by HOTAIR knockdown in GIST-T1 cells

XLS file - 47K, Predicted miR-196a target genes whose expression was reduced in GISTs overexpressing miR-196a

XLS file - 28K, Correlation between miR-196a expression and the GIST risk category

XLS file - 55K, HOTAIR-induced PRC2 target genes whose expression was reduced in GISTs overexpressing HOTAIR

XLS file - 27K, GSA results for differentially expressed genes in GISTs with and without miR-196a overexpression

XLS file - 31K, Summary of miR-196a expression results in each GIST risk category

XLS file - 29K, Summary of GIST samples used in the gene expression microarray analysis

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In flexible gastrointestinal (GI) endoscopy, endoscopic insufflation is crucial and directly affects visualization. Optimal visualization enables endoscopists to conduct better examinations and administer optimal treatments. However, endoscopic insufflation is typically performed manually and is subjective. We aimed to measure the GI endoluminal pressure during flexible GI endoscopy. Participants underwent esophagogastroduodenoscopy (EGD) at our endoscopy center. Pressure measurement was conducted after completing diagnostic or follow-up EGD. The endoluminal pressure in the esophagus and stomach was measured at 1-s intervals for 1 min while performing EGD for observational and diagnostic purposes. During the measurements, the endoscopists maintained what they subjectively considered to be adequate exposure for screening for lesions by dilating the lumen. Eighty patients were enrolled in this study. The upper GI endoluminal pressure was assessed during EGD without adverse events. The esophageal endoluminal pressure averaged 8.9 (− 3.0 to 20.7) mmHg, and the gastric endoluminal pressure averaged 10.0 (3.0–17.9) mmHg; the upper GI endoluminal pressures were not affected by patient-related factors or the number of endoscopists’ postgraduate years. We have successfully obtained the GI endoluminal pressures during EGD. Further accumulation of these data may lead to more stable and reproducible flexible endoscopic diagnosis and intervention.

The case is a 50-year-old woman. Colonoscopy performed by a local doctor for the purpose of stool occult blood positive revealed a 15 mm tumor in the lower rectum, biopsy showed chromogranin positive, synaptophysin positive, and Ki-67 index1% showed a neuroendocrine tumor(NET), G1 was diagnosed and introduced. Colonoscopy revealed a smooth- surfaced circular hemispherical tumor with a lower edge 30 mm from the anal margin and 20 mm from the dentate line, and EUS showed 10.7×5.2 mm in layers 2 to 3. It was visualized as a well-defined hypoechoic tumor. Contrast-enhanced CT examination showed a 12×5 mm mass showing a contrast-enhancing effect, and no lymphadenopathy or distant metastasis was observed. Contrast-enhanced MRI showed no evidence of pelvic lymphadenopathy. Based on the above, it was diagnosed that NET, G1, and infiltration to the submucosa exceeding 10 mm. Although endoscopic resection as a diagnostic treatment was also an option, we determined surgical resection policy, therefore we performed laparoscopic rectal intersphincteric resection and upper D2 dissection. Histopathological findings showed a tumor of 11×8 mm infiltrating the submucosa( 5,000μm)with metastasis to the pararectal lymph nodes, and the diagnosis was T1b, N1, Ki-67 index 3%, Ly1, V1a, NET G2, pStage ⅢB. Her postoperative course was uneventful, and 6 months later, we performed her artificial anal closure. One year after the operation, there are frequent bowel movements but no fecal incontinence and she is alive without recurrence. For rectal NET with a tumor diameter of 10 mm or more, radical surgery with dissection is recommended because of the high risk of lymph node metastasis. In this case lymph node metastasis was observed surgical resection according to the above reason, but endoscopic resection was possible except that the preoperative size exceeded 10 mm to 0.7 mm and the distance from the anus was short, therefore it took some thought to decide the policy.

In our hospital, we measure the body composition of patients undergoing gastrointestinal surgery. For patients who have a skeletal muscle mass(SMM)of less than 90% of the ideal, we provide them with guidance on having oral nutritional supplements(ONS)and self-exercise therapy. Therefore, we perform operations after taking measures on preserving/improving patient's preoperative conditions. This study was aimed to evaluate the effects on body weight, SMM, and fat mass(FM)in the patients scheduled for gastrectomy.From January 2017 to December 2020, we retrospectively analyzed 64 gastric cancer patients whose body composition changes were measured at the time of initial diagnosis and immediately before surgery. The body composition was measured by a nutritionist using the BIA method, while the self-exercise therapy was instructed by a rehabilitation therapist.A total of 64 patients were divided into 2 groups: ONS group(36 patients)and Non-ONS group(28 patients). The median preoperative ONS administered to the ONS group was 15 packs. Body weight change showed a significant difference between the 2 groups(+0.73% and -0.91%[p0.01]in the ONS group and Non-ONS group respectively). SMM change showed no significant difference between the 2 groups(+1.18% and +0.64%[p=0.19]in the ONS group and Non-ONS group respectively). Likewise, FM change showed no significant difference between the 2 groups(-1.08% and -3.50%[p=0.39]in the ONS group and Non-ONS group respectively).This study suggested that SMM and FM could be preserved, and body weight could be increased by the support of preoperative ONS administration even in patients with gastric cancer close to having sarcopenia.

A 69-year-old man presented to our hospital with chief complaints of epigastral pain and nausea, was diagnosed with intestinal obstruction after gastric surgery. Abdominal CT performed on the admission showed the tumor located on the terminal ileum. On colonoscopy, type 1 cancer was found near the Bauhin valve in the ileum, and suspected primary ileal carcinoma. Laparoscopic ileocecal resection was performed. The pathological diagnosis was moderately differentiated adenocarcinoma, and the pathological stage was T3(SS), N1(3/16), M0, Stage ⅢA. Although superficial surgical site infection was occurred, the patient was discharged 11 days after surgery. He hoped to adopt without adjuvant chemotherapy, so he has been followed as outpatient. Twenty one months since the surgery, there has been no evidence of cancer recurrence.

An 80-year-old man visited our hospital because of abdominal distension and epigastralgia. He was diagnosed esophageal cancer(Mt, SCC, T3N0M0, Stage Ⅱ). Because he was elderly, he received chemoradiotherapy(CRT)with S-1. At 54 Gy/27 Fr, he was admitted to the hospital because of cough exacerbation, fever, and food intake loss. A chest and abdominal CT showed a pneumonia pattern. First, antibiotics were started for suspected bacterial pneumonia. Nevertheless, elevation of inflammatory reactions and continuous fever were observed. As interstitial pneumonia was suspected, we started to administer an injection of prednisolone 60 mg. His respiratory symptoms were improved. However, we observed that disseminated erythema of the trunk spread throughout the body and liver enzymes further increased. As blood examination revealed elevated CMV-IgG antibody and C7-HRP positive, we diagnosed cytomegalovirus(CMV)reactivation. Administration of ganciclovir improved liver damage and disseminated erythema. He discharged our hospital while the steroid dose was reduced and valganciclovir continued administrating. The therapeutic effect of esophageal cancer was partial response(PR). We are following his symptoms and CT scan while adjusting the steroid dose. This is a rare case of CMV reactivation due to immunosuppression caused by steroids therapy during CRT against esophageal cancer. We should be aware of CMV infection during CRT and steroid therapy.

Although 3-field lymph node dissection (3-FLD) is often performed for thoracic esophageal squamous cell carcinoma (ESCC), the clinical effects of cervical lymph node dissection in addition to mediastinal and abdominal dissections on postoperative complications remain unclear. A total of 367 ESCC patients who underwent curative esophagectomy for thoracic esophageal cancer in our hospital from 2010 to 2015 were included in the study: 157 patients who underwent 2-field lymph node dissection (2-FLD) and 210 patients who underwent 3-FLD. Clinicopathological parameters and postoperative complications based on the Clavien-Dindo classification were compared between the two groups. We performed propensity score matching (PSM) analyses to compare the groups with well-balanced backgrounds. In terms of patient background, clinical T (p < 0.001), N (p < 0.001), and M (p = 0.002) stage of tumor was significantly more advanced; therefore, preoperative treatment was more frequently performed in the 3-FLD group than in the 2-FLD group (91.0% vs. 79.0%, P< 0.001). However, perioperative parameters including operation time, blood loss, and the number of dissected mediastinal and abdominal lymph nodes did not differ between the groups. In terms of postoperative complications, the occurrence rate of pneumonia increased significantly in patients with 3-FLD compared to 2-FLD (grade III or higher: 10.5% vs. 3.2%, P= 0.025). Although the duration of systemic inflammatory response syndrome (SIRS) was longer in the 3-FLD group than in the 2-FLD group (median 3 days vs. 2 days, P= 0.025), other postoperative parameters (including the highest level of postoperative serum C-reactive protein, intensive care unit stay, re-operation rate, and postoperative hospital stay) were similar between the groups. After PSM, the differences in the background between the groups disappeared. PSM analysis showed that there was no significant difference in each complication between the groups. The duration of SIRS tended to be longer in the 3-FLD group than in the 2-FLD group, but the difference was not significant. The field of lymphadenectomy negatively impacted the short-term outcome in ESCC patients in terms of pneumonia and inflammatory response. However, because the results of the PSM analyses indicate that the short-term outcome was similar between the two groups, 3-FLD could be as feasible as 2-FLD in ESCC patients.

An efficient method has been developed for the Barbier-type alkylation reaction of bulky esters or ketones in the presence of metallic strontium and alkyl iodides. The reaction proceeded smoothly at ambient temperature to afford the fully alkylated corresponding alcohols in better yield than those obtained when using the corresponding Grignard reagents. The method is especially effective for introducing isobutyl or neopentyl groups into phenyl or adamantyl skeletons.

Available online 8 November 2016, Our aim is to study the modular representation theory of coherent configurations. Let p be a prime. We consider structures of modular adjacency algebras of coherent configurations obtained from combinatorial designs. The structures of standard modules of modular adjacency algebras provide more information than p-ranks of incidence matrices of combinatorial designs. (C) 2016 Elsevier Inc. All rights reserved., Article, LINEAR ALGEBRA AND ITS APPLICATIONS. 514:174-197 (2017)

The safety and feasibility of the chemotherapy for super-elderly patients over 85 years old have not been clarified yet. We report an extremely aged patient with recurrent rectal cancer that was successfully treated with chemotherapy. A 85-year-old woman underwent Hartmann procedure for rectal cancer. Nine months after surgery, CT scan revealed liver metastases in S5 and S7. We administered capecitabine plus bevacizumab chemotherapy. Liver metastases were disappeared after 6 courses. Although grade 2 hypertension was appeared, no other adverse event occurred. However, due to lung metastases, we attempted irinotecan plus bevacizumab as second line treatment. After 10 courses, general fatigue was gradually developed, so we changed the frequency of chemotherapy from biweekly to triweekly administration. The patient's performance status score has been kept 0, and she has been under treatment as an outpatient for 3 years. The chemotherapy for extremely aged patients with recurrent colorectal cancer was suggested to be safe and feasible under the adequate dose reduction and interval adjustment.

Reflux following an esophagectomy with gastric conduit reconstruction in the posterior mediastinum is a clinically significant problem. In this study, we investigated the frequency and impact of reflux on the quality of life (QOL) among 158 patients who underwent an esophagectomy for esophageal cancer using an original questionnaire and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Version 3.0 (EORTC QLQ-C30). Reflux frequency was assessed using the original questionnaire. The number of patients who complained of reflux every day, two or three times a week, once a week, or less than once a week was 16 (10.1%), 21 (13.3%), 26 (16.5%), and 60 (38.0%), respectively. Out of 35 patients (22.2%) reported no reflux symptoms. Patients were divided into two groups: those with reflux ≥ once/week (63 patients) and those with low frequency of symptoms (95 patients). Time elapsed following surgery was the only factor to influence reflux frequency. Reflux frequency decreased within two years of surgery; however, the frequency plateaued after more than two years. QOL was assessed using the EORTC QLQ-C30. The ≥ once/week reflux group had a significantly lower global health status score than the low-frequency reflux group (59.6 ± 24.2 vs. 70.8 ± 20.7; P = 0.007). In addition, the ≥ once/week reflux group had a significantly lower social functioning score than the low-frequency reflux group (81.6 ± 24.1 vs. 88.4 ± 19.8; P = 0.035). Regarding symptoms, the ≥ once/week reflux group had significantly higher scores for fatigue, nausea, and vomiting, dyspnea and insomnia compared to the low-frequency reflux group (fatigue: 42.4 ± 21.9 vs. 28.9 ± 18.4, P < 0.001; nausea and vomiting: 17.3 ± 17.1 vs. 4.9 ± 10.6, P < 0. 001; dyspnea: 29.2 ± 26.0 vs. 21.7 ± 26.8, P = 0.043; insomnia: 22.2 ± 31.1 vs. 10.5 ± 21.7, P = 0.015). Thus, reflux after an esophagectomy was associated with a lower QOL.

The efficacy and feasibility of laparoscopic surgery (LAP) for gastric GISTs5 cm has not been adequately assessed. Here we investigated the clinical outcomes of these patients.Twenty-seven consecutive patients who underwent resection for gastric GISTs5 cm were enrolled in this retrospective study. We assessed the tumor characteristics, surgical outcomes, tumor recurrence, and patient survival in the open surgery (OPEN) group and in the LAP group.The tumor size in the OPEN group was larger than that in the LAP group, but there were no differences in the mitotic count. There were no differences in operative complications. Finally, there were no differences in the disease-free and no patients in the LAP group died.In patients with gastric GISTs5 cm, LAP can be performed with outcomes equivalent to those of OPEN if patient selection and intraoperative judgment are appropriate.

A36 -year-old man with intellectual disabilities consulted a local physician complaining of a cough, and an abdominal mass was observed on palpation. The patient visited our hospital for close examination. Abdominal contrasting CT revealed a mass with a clear boundary with heterogeneous contrast on the left side of his abdominal cavity. We performed a laparotomy and observed that the tumor originated from the greater omentum. The tumor size was 9×8×6 cm and its weight was 200 g. Histopathologic examination showed hyperplastic spindle-shaped tumor cells with less nuclear fission. Immunohistochemical staining showed that the tumor was positive for CD34, CD99, and bcl-2, slightly positive for p53, and negative for S-100, a- SMA, c-kit, and desmin. Based on the results, a diagnosis of solitary fibrous tumor (SFT) was made. The patient has not shown any recurrence 8 months after surgery.

A 75-year-oldman presenting with obstructive jaundice was referredto our hospital. Basedon a diagnosis of carcinoma of the ampulla of Vater, we performed pancreatoduodenectomy. Postoperative histopathological examination revealed a welldifferentiated papillotubular adenocarcinoma, T3, N0, M0, Stage III . Six months after surgery, an isolatedliver metastasis in S6 was identifiedon CT scan andMRI; therefore, we administeredgemcitabine plus cisplatin chemotherapy. After 6 courses of this regimen, a clinical complete response(CR)was obtained. After 12 courses, the clinical CR continued; however, grade 3 lower-extremity peripheral neuropathy appeared. Therefore, gemcitabine monotherapy was administered as second line chemotherapy. However, multiple liver metastases appearedandthe patient passedaway owing to exacerbation of the disease 2 years after initiating chemotherapy. Although recurrent ampullary carcinoma is difficult to treat, our patient had a long-term survival. Here we report the details of our case and review the relevant literature.

Curative treatment for unresectable colon cancer is difficult, and therefore, chemotherapy is often administered in an attempt to improve the prognosis. However, the safety andfeasibility of chemotherapy for elderly patients over 80-years-old have not yet been clarified. We report an elderly colon cancer patient with multiple liver metastases who was successfully treatedwith mFOLFOX6 andsLV5 FU2 chemotherapy. The patient was an 83-year-old-man who was referredto our hospital. After performing sigmoidectomy, we administered mFOLFOX6 chemotherapy. After 5 courses, the regimen was changed to sLV5FU2 owing to grade 3 neuropathy. Liver metastases disappearedanda complete response was obtained1 year after chemotherapy administration. Twenty-four courses of sLV5FU2 chemotherapy had been safely performed. Although grade 1 neutropenia developed, no other adverse event was observed. Currently, the patient is alive without recurrence. Chemotherapy for elderly patients is both feasible and safe.

Although no consensus is available on the treatment of esophageal squamous cell carcinoma (ESCC) invading adjacent organs (T4), establishing effective induction treatments is crucial to altering an unresectable status and achieving curative resection. Here, we evaluated the efficacy of chemotherapy using 5-fluorouracil, cisplatin, and docetaxel (DCF) as the initial induction treatment for T4 ESCC. Fifty patients without distant metastasis who underwent initial induction chemotherapy using DCF for T4 ESCC were propensity score-matched with 50 patients who underwent radiotherapy concurrent with cisplatin and 5-fluorouracil (CRT). In the DCF group, 24 (48.0%) patients underwent surgery, achieving a 64% clinical response rate compared to 72.0% for induction CRT. CRT was also performed in another 24 (48.0%) patients in the DCF group in whom surgical resection was not indicated. The DCF group had significantly higher overall resectability than the CRT group (78.0% vs. 48.0%, P = 0.0017). The esophageal perforation rate during induction treatments was significantly lower in the DCF group than the CRT group (4.0% vs. 18.0%, P = 0.0205). Prognosis was significantly better in the DCF group than the CRT group (5-year cancer-specific survival 42.1% vs. 22.2%, P = 0.0146). Thus, induction DCF chemotherapy in patients with T4 ESCC reduced esophageal perforation and increased overall resectability, leading to better survival than CRT alone. Therefore, DCF chemotherapy may be an effective and safe option for initial induction treatment of T4 ESCC.

Computed tomography (CT) is the major diagnostic tool for clinical management of gastric cancer. However, minimal residual disease and peritoneal dissemination, the most frequent recurrent patterns in gastric cancer, are typically difficult to detect with CT. Circulating tumour DNA (ctDNA)—fragmented DNA released from cancer cells into the bloodstream—is an emerging candidate marker to follow disease progression (Schwarzenbach et al, 2011). Previous studies have indicated that ctDNA levels correlate with tumour burden in colon cancer (Diehl et al, 2008) and breast cancer (Dawson et al, 2013). However, no comparative studies have been conducted in gastric cancer, and it is necessary to examine the possibility that ctDNA can be used for monitoring disease status, especially minimal residual disease and peritoneal dissemination. We previously developed a system to detect EGFR mutations in the plasma of lung cancer patients using a massively parallel sequencer (Kukita et al, 2013) and applied it to monitor advanced gastric cancer.

Background and study aims: Steady pressure automatically controlled endoscopy (SPACE) is a new insufflation system that provides constant carbon dioxide (CO2) insufflation pressure during prolonged procedures. The system consists of an overtube, a surgical insufflator, and a newly developed leak-proof valve. The aims of this study were to validate the feasibility and safety of SPACE for esophageal endoscopic submucosal dissection (ESD). Patients and methods: This was a clinical phase I trial, involving 10 patients who underwent esophageal ESD. The primary end point was the rate of adverse events within 30 days (grade 0 to 4). Secondary end points were changes in partial pressure of carbon dioxide (PaCO2) and vital signs during ESD, completion rate of ESD, and degree of abdominal distension by patient assessment and radiographic grading. Results: All adverse events were Grade 2 or less. Mild PaCO2 elevation after ESD was noted; however, no associated symptoms were reported. The procedure was completed under SPACE alone in 8 of 10 patients. Minimal post-procedural bowel distension was observed. Conclusions: In this small pilot study, SPACE was feasible and appeared to be safe. Further study with larger case numbers is required to demonstrate efficacy and safety. Clinical trial registration: UMIN000005434

Although its theoretical usefulness has been reported, the true value of automatic smoke evacuation system in laparoscopic surgery remains unknown. This is mainly due to the lack of objective evaluation. The purpose of this study was to determine the efficacy of the automatic smoke evacuator in laparoscopic surgery, by real-time objective evaluation system using an industrial smoke-detection device. Six pigs were used in this study. Three surgical ports were placed and electrosurgical smoke was generated in a standard fashion, using either a high-frequency electrosurgical unit (HF-ESU) or laparosonic coagulating shears (LCS). The smoke was evacuated immediately in the evacuation group but not in the control nonevacuation group. The laparoscopic field-of-view was subjectively evaluated by ten independent surgeons. The composition of the surgical smoke was analyzed by mass spectrometry. The residual smoke in the abdominal cavity was aspirated manually into a smoke tester, and stains on a filter paper were image captured, digitized, and semiquantified. Subjective evaluation indicated superior field-of-view in the evacuation group, compared with the control, at 15 s after activation of the HF-ESU (P

Use of rigid instruments via transvaginal (TV) route has been proposed as a practical alternative to natural orifice translumenal endoscopic surgery (NOTES) using flexible devices. However, its safety has not been fully evaluated for each abdominal organ with different positional relationship to the vagina. The aim of this study is to obtain baseline anatomical data necessary for safer use of rigid TV instruments, by three-dimensional (3-D) radiologic measurements. A retrospective study was conducted on 51 consecutive female Japanese patients with aortic aneurysm who underwent whole-body multidetector computed tomography as preoperative evaluation. The gallbladder (GB), esophagogastric junction (EGJ), and spleen were located on 3-D images, and the following were obtained: (1) the distance from the vagina, (2) the transverse deviation from the midline, and (3) the sagittal deviation from the “vagina–promontory (V–P)” line. The median distance from the vagina was 26.1 cm for GB, 30.6 cm for EGJ, and 31.1 cm for spleen. The transverse deviation from the midline was 17.7° for GB, 7.0° for EGJ, and 12.9° for spleen. The sagittal deviation from the V–P line was 7.6 degrees for GB, −7.0° for EGJ, and −10.3° for spleen. The percentage of “negative angle” cases, which means that the target is located “below” the V–P line, was only 9.8 % for GB versus 88 % for EGJ and spleen. The intra-abdominal length of TV instruments should be more than 35 cm in Japanese population. GB is widely deviated from the midline and therefore can be safely approached even with rigid/straight instruments. Access to more midline and distant targets may suffer from interference by the sacral promontory, and be potentially dangerous in terms of risk of compression injury by rigid and straight instruments.

A 67-year-old man had a gastric polyp diagnosed on screening. Atrophic changes in the upper gastric mucosa were seen on upper gastrointestinal endoscopy. In addition, endoscopy revealed in the middle area of the stomach wall a 10 mm polyp that was diagnosed as a carcinoid tumor through biopsy. Blood serum gastrin was elevated at 2,800 pg/mL.We diagnosed a Rindi Type 1 gastric carcinoid. The patient was planned to be treated with surgical laparoscopy assisted distal gastrectomy (LADG); however, the procedure was changed to intraoperative laparoscopy assisted total gastrectomy (LATG). Chromogranin-positive tumor pathological findings in the mucous membrane submucosa and in the muscularis mucosae endocrine cell micronest (ECM) were widespread. There was no obvious vascular invasion. After the surgery, the serum gastrin level normalized and the patient remains alive.

The safety and feasibility of chemotherapy for super-elderly patients (over 85 years old) has not been clarified yet. We report an extremely aged patient with recurrent rectal cancer that was successfully treated with capecitabine plus bevacizumab chemotherapy. An 85-year-old-woman underwent a Hartmann procedure for rectal cancer. Nine months after surgery, tumor markers were elevated. CT and MRI revealed liver metastases in S5 and S7. We administered capecitabine plus bevacizumab chemotherapy. Tumor makers were normalized after 2 courses, and the liver metastases disappeared after 6 courses. Although Grade 1 hypertension developed, no other adverse event occurred. Chemotherapy has been safely performed for 20 courses. The patient's PS score has been maintained at 0, and she has been under treatment as an outpatient. We suggest that capecitabine plus bevacizumab chemotherapy is an effective regimen for extremely aged patients with recurrent colorectal cancer.

Background and study aims: A new overtube system has been developed for steady pressure automatically controlled endoscopy (SPACE) in the gastrointestinal tract. The objectives of this study were to validate the feasibility and safety of SPACE in the esophagus, and to evaluate its potential advantages over conventional (manually insufflating) endoscopy in endoscopic submucosal dissection (ESD). Methods: This was a multicenter preclinical trial using acute porcine models (n = 20). In Experiment 1 (feasibility/safety study), SPACE was attempted in the esophagus with continuous monitoring of cardiopulmonary parameters and intraluminal pressures in the downstream bowel. Different insufflation pressures were tested to optimize the insufflation condition. Each session was video-recorded and scored by blinded reviewers. In Experiment 2 (randomized trial), esophageal ESD was attempted using either SPACE or conventional endoscopy, and results were compared. Results: In Experiment 1, SPACE was performed safely without intraluminal pressure elevation in the downstream bowel. According to video review, SPACE provided more stable, reproducible, and rapid visualization than conventional endoscopy. The insufflation pressure was optimized at 14 mmHg for esophageal SPACE. In Experiment 2, ESD was completed in all animals. The ESD time was significantly shorter with SPACE compared with conventional endoscopy (1326 vs. 1616 seconds; P = 0.009). Responses to questionnaires showed that 94 % – 100 % of participants considered SPACE to provide improved exposure and more uniform tissue tension than conventional endoscopy. Other data were comparable. Conclusions: SPACE is feasible, safe, and potentially effective for complicated endoscopic procedures, such as ESD. SPACE improves and standardizes endoscopic exposure and tissue tension. A clinical study is required to further confirm its safety and clinical effectiveness.

Inflammation is a crucial driving force in the development of gastric cancers (GCs). Accordingly, persistent activation of STAT3, a transcription factor pivotal in regulating both inflammation and oncogenesis, is often detected in GC, although its mechanism remains elusive. Suppressor of cytokine signaling-1 (SOCS-1) is a negative regulator of proinflammatory cytokine signaling and SOCS-1 gene methylation is frequently detected in various cancers including GC. However, the significance of SOCS-1 methylation in GC cells remains unexplored. Our study is undertaken to evaluate the role of SOCS-1 in GC cell proliferation and its effect on signaling pathways in GC cells. Among five GC cell lines, SOCS-1 gene was methylated in all cell lines and constitutive STAT3 phosphorylation with elevated endogenous IL-6 production was detected in two cell lines (NUGC-3 and AGS). Unexpectedly, anti-IL-6R antibody inhibited neither cell proliferation nor STAT3 phosphorylation in NUGC-3 and AGS. In contrast, enforced SOCS-1 expression by adenoviral vector (AdSOCS-1) markedly suppressed STAT3 phosphorylation and proliferation of NUGC-3 and AGS cells in vitro. Interestingly, the antiproliferative effect of SOCS-1 was attributable not only to the inhibition of STAT3 but also to that of p38 MAPK activity, and chemical inhibitors of JAK/STAT and p38 MAPK signaling effectively suppressed proliferation of these GC cells. Furthermore, treatment with AdSOCS-1 in vivo significantly suppressed GC proliferation in a xenograft model. These results suggest that SOCS-1 gene methylation is a critical step in the development of GC, and enforced expression of SOCS-1 may represent a novel therapeutic approach for the treatment of GC.

Background Natural orifice transluminal endoscopic surgery (NOTES) requires fast and steady CO 2 insufflation into the intraluminal and intra-abdominal spaces through a flexible endoscope. However, an optimal endoscopic insufflation system has yet to be determined. Objective To verify the performances of 2 currently available CO 2 insufflators in an experimental NOTES setting: (1) an automatic pressure-regulated surgical insufflator (UHI-3) and (2) a manual endoscopic insufflator (UCR). Design An inanimate bench study followed by an acute animal experiment. Setting Osaka University and Olympus Research and Development Department. Main Outcome Measurements The UHI-3 or UCR was connected to an endoscope of differing length and diameter via an insufflating line of differing length and diameter. The flow rates at the tip of the endoscope (bench test), the time to establish pneumoperitoneum, and the time to re-establish pneumoperitoneum after forceful suction (porcine model) were obtained. Results The UHI-3 failed to feed CO 2 through an insufflating channel but fed CO 2 via a working channel but required a large channel (>3 mm) and a wide insufflating line (>7 mm) to accomplish an acceptable flow rate. UCR fed CO 2 through the insufflating channel; however, the time taken to establish pneumoperitoneum and the time taken to re-establish pneumoperitoneum after forceful suction were longer compared with the time taken for UHI-3 insufflation via the working channel or laparoscopic cannula. Limitations Bench/animal study with small sample numbers; no human trial. Conclusions The currently available CO 2 insufflators are not optimal for NOTES. Modification of an endoscopic insufflation system and/or development of a dedicated overtube with an insufflating function are therefore essential.

Gastrointestinal stromal tumor (GIST) is considered to be driven by a gain-of-function mutation in the KIT or PDGFRA gene. Cure can be obtained only by complete surgical removal of the GIST; however, imatinib, an inhibitor of KIT and PDGFRA, is indicated for advanced, recurrent, and/or metastatic GISTs. Imatinib exhibited remarkable clinical effects on advanced GISTs, with substantial tolerability. Its efficacy greatly depends on the genotype of GIST. The drug, however, met intrinsic or acquired resistance during the treatment, of which the molecular mechanisms were mostly dependent on the genotype of GIST, including primary mutations or secondary mutations in the kinase domains of the corresponding target genes, respectively. Although sunitinib had substantial effects on imatinib-resistant GIST, this drug also encountered primary or secondary resistance depending on the genotype. Thus, advanced GIST may require multidisciplinary treatment. Because resistance mechanisms show some regularity, it is hoped that, in the near future, we may be able to develop a new drug to which resistance does not occur easily, based on scientific evidence.

Isolated granulomatous inflammation of the appendix is extremely rare, and its etiology is still unknown. Thus, differentiating between idiopathic granulomatous appendicitis and isolated appendiceal Crohn's disease is difficult. We report a case of idiopathic granulomatous appendicitis with long-term follow-up after surgery. A 26-year-old woman was referred to our hospital for investigation of persistent right lower abdominal pain. Abdominal computed tomography showed a mass, suggesting an inflammatory tumor around the appendix; thus, we suspected subacute appendicitis and performed laparoscopically assisted ileocecal resection. Histological examination of the resected specimen revealed several noncaseous epithelioid granulomas in the wall of the appendix, but no foreign bodies, obstructing lesions, or parasites. Stains for acid-fast bacillus and fungi, and serology for yersinia were all negative. The patient has been followed up for 9 years and remains asymptomatic. This clinical course suggests that her isolated granulomatous appendicitis was idiopathic granulomatous appendicitis unrelated to Crohn's disease.