佐田 尚宏

BACKGROUND: The sentinel lymph node (SLN) biopsy technique using superparamagnetic iron oxide (SPIO) as a tracer instead of radioisotopes has been described. To further advance this technique, we evaluated preoperative SPIO-MR sentinel lymphography to facilitate the accurate identification of the lymphatic pathways and primary SLN. METHODS: A prospective study was performed in ten patients with breast cancer and clinically negative axillary lymph nodes. None of the patients received preoperative chemotherapy. After 1.6 ml of SPIO (ferucarbotran) was injected in the subareolar breast tissue, sentinel axillary lymph nodes were detected by MRI in T2*-weighted gradient echo images and resected using the serial SPIO-SLN biopsy procedure with a handheld magnetometer. RESULTS: In one patient, gadolinium-enhanced MR imaging was performed at the same time as SPIO-MR lymphography, and this patient was excluded from further analysis. In all patients (9/9) SLNs were detected by SPIO-MR sentinel lymphography and successfully identified at surgery. The number of SLNs detected by lymphography (mean 2.7) significantly correlated with SLNs identified at surgery (mean 2.2). One patient had nodal metastases. In one patient, skin color changed to brown at the injection site and resolved spontaneously. There were no severe reactions to the procedure or complications in any patient. CONCLUSIONS: This is the first study to evaluate SPIO both as a contrast material in MR sentinel lymphography and as a tracer in SLN biopsy using an integrated method. The acquired three-dimensional imaging demonstrated excellent image quality and usefulness to identify SLN in conjunction with SLN biopsy.

The growth, invasiveness and metastasis of human cancers are determined not only by cancer cells, but also by their microenvironment. Activated stromal fibroblasts promote tumor progression by secreting growth factors. In the present study, we focused on interrelations between cancer and fibroblasts, the main component of tumor stroma. We retrospectively analyzed the relations of mortality to clinical, pathological, and α-smooth muscle actin (α-SMA) characteristics in 97 consecutive patients with esophageal squamous cell carcinoma (ESCC). In vitro, we used TE-11, KYSE150 and KYSE220 ESCC cell lines and isolated esophageal stromal fibroblasts, some of which were immortalized. Migration assays were conducted to assess the effects of fibroblasts on cancer-cell migration and 3-dimensional organotypic cultures. In vivo, TE-11 and KYSE220 cells plus immortalized fibroblasts were co-transplanted subcutaneously in Nod/Scid mice to assess the effects of fibroblasts on tumorigenicity. Clinicopathologically, the α-SMA expression of cancer stroma was correlated with venous invasion (p<0.01), nodal involvement (p=0.02), recurrence (p=0.01), and was a predictor of survival in patients with stage I and II ESCC (p=0.04). In vitro, the presence of fibroblasts strongly promoted the migration of TE-11, KYSE150 and KYSE220 cells. On organotypic culture, stromal invasion was observed only in the presence of immortalized fibroblasts. In vivo, tumors developed or grew in a fibroblast‑dependent manner after implantation. Our findings provide evidence that stromal fibroblasts and tumor cells interact to promote tumor progression in ESCC. In patients with earlier stage ESCC, α-SMA may be a predictor of mortality. Inhibition of paracrine systems associated with tumor fibroblasts may slow or reverse tumor progression, potentially leading to the development of new targeted therapies.

BACKGROUND: The goal of this study is to examine changes in pancreatic perfusion due to pneumoperitoneum using perfusion CT in vivo. METHODS: Three pigs were studied. Under general anesthesia, pneumoperitoneum was induced to 16 mm Hg. Perfusion CT scans were acquired at a rate of 1 image per 2 seconds for 60 seconds. Scans were repeated 5 days later without pneumoperitoneum using the same protocol, in the same animals. The time density curve, color map, peak enhancement, time to peak, blood flow, blood volume, and permeability were evaluated. RESULTS: In the presence of pneumoperitoneum, peak enhancement in radiodensity was decreased and time to peak was increased, and both blood flow and blood volume decreased. However, there was no consistent change in permeability observed. CONCLUSION: This study demonstrates that pneumoperitoneum quantitatively results in decreased blood flow and blood volume to the pancreas in an in vivo animal model.

A 41-year-old woman was admitted with upper abdominal pain, vomiting and fever. Abdominal CT scan showed a colo-duodenal fistula with inflammatory thickening of the transverse colon. The patient's general health was poor because of hypoalbuminemia and coagulopathy. Endoscopy showed a fistula at the lower duodenal angle and the stomach was filled with refluxed stool. Ileostomy and percutaneous endoscopic gastrostomy were performed at that time and a double lumen gastro-jejunostomy inserted through the gastrostomy to allow both gastric drainage and distal enteral feeding. Nutrition support was gradually converted from parenteral to enteral feeding. Colonoscopy showed stenosis of the transverse colon with a colo-colonic fistula near the stenosis. Two months later, right hemi-colectomy and closure of the colo-duodenal fistula were performed. The resected specimen showed stenosis and a fistula in the transverse colon due to Crohn's disease. The colo-colonic fistula was present and the colo-duodenal fistula had almost closed due to fibrosis. The postoperative course was uneventful and the patient was discharged after administration of infliximab. Use of a double lumen gastro-jejunostomy tube was effective in improving the patient's general condition. This therapeutic strategy allowed the safe conduct of major resection in a high-risk patient.

Rational treatment for neoplasms of the duodenal papilla (NDPs) is still controversial, especially for early stage lesions. Total papillectomies are indicated in patients expected to have adenomas, adenocarcinoma in an adenoma, or mucosal adenocarcinomas with no lymph node metastases. However, the preoperative pathological evaluation of NDPs is still challenging and often inaccurate, mainly because of the complicated anatomical structures involved and the possibility of an adenocarcinoma in an adenoma. Herein, we introduce a new method of total papillectomy, the extraduodenal papillectomy (ExDP). In this method, papillectomy is undertaken from outside of the duodenum, instead of resection from the inside through a wide incision of the duodenal wall as is done in conventional transduodenal papillectomy (TDP). The advantages of ExDP are precise and deeper cutting of the sphincter and shorter exploration time of the tumor compared to conventional TDP. We demonstrate three representative patients, all of whom had an uneventful postoperative course. One of them subsequently underwent a pylorus preserving pancreatoduodenectomy after detailed postoperative pathological evaluation. Including that patient, no recurrence has occurred with 37-46 months of follow-up. In conclusion, ExDP is regarded as a "total biopsy" for early stage borderline lesions and a feasible, less demanding alternative method for the treatment of NDPs.

症例は66歳の女性で，嘔吐と体重減少を主訴に当院を受診した．腹部CTにて十二指腸周囲，肝十二指腸間膜，小網に至る気腫像，胃十二指腸下行脚部の著明な拡張，水平脚部のcaliber changeを認めた．さらに，多量の腹腔内free airと十二指腸周囲の後腹膜ガス像も認めたため，上腸間膜動脈症候群による腸管気腫症および上部消化管穿孔の診断で緊急手術を施行した．術中所見では胃十二指腸の拡張，および十二指腸気腫を認めたが穿孔所見や腹水は認めなかった．経胃腸瘻造設のみ行い，術後経過は良好であった．腸管気腫症の原因は多岐にわたり，時にfree airを伴い消化管穿孔との鑑別が困難なことがある．患者の臨床所見と腸管気腫症の成因を詳細に検討し治療方針を決定することが重要で，審査腹腔鏡も選択肢の一つと考えられた．

Purpose: This retrospective study evaluates the clinical course and outcomes of patients who underwent surgery for strangulated hernias. Methods: Among 520 groin hernias from 2001 to 2012, 51 inguinal and 42 femoral hernias were strangulated and operated emergently at a tertiary referral center. Perioperative factors, patient profiles, and time interval to surgery (Ttotal = time from onset to surgery, T1 = time from onset to initial evaluation, T2 = time from the first hospital to the tertiary center, T3 = time from admission at the tertiary center to surgery, Ttotal = T1 + T2 + T3) were analyzed in patients with strangulation, then compared between two groups, the bowel resection (BR) group and the non-bowel resection (NBR) group. Results: T1, T2 and Ttotal in the bowel resection group were significantly longer than those in the non-bowel resection group (P &lt  0.05). Patients who presented initially to the tertiary center (T2 = 0) had a significantly lower resection rate than patients transported from other hospitals (24 vs. 44 %, P = 0.048). There was no significant difference in morbidity between the BR and NBR groups (35 vs. 24 %, P = 0.231). Conclusions: The elapsed time from onset to surgery, especially T1 and T2, is the most important prognostic factor in patients with strangulated groin hernias. Early diagnosis and transportation are essential for good outcomes.

Pancreatic islet transplantation has received widespread attention as a promising treatment for type 1 diabetes. However, islets for transplantation are subject to damage from a number of sources, including ischemic injury during removal and delivery of the donor pancreas, enzymatic digestion during islet isolation, and reperfusion injury after transplantation in the recipient. Here we found that protein fractions secreted by mesenchymal stem cells (MSCs) were capable of activating preserved islets. A conditioned medium from the supernatant obtained by culturing adipose tissue MSCs (derived from wild-type Lewis rats) was prepared for 2 days in serum-free medium. Luc-Tg rat islets to which an organ preservation solution was added were then incubated at 4°C with fractions of various molecular weights prepared from the conditioned medium. Under the treatment with some of the fractions, by 4 days the relative luminescence intensities (representative of the ATP levels of the cold-preserved islets) had increased to over 150% of their initial values. Our novel system may be able to restore isolated islets to the condition they were in before transport, culture, and transplantation.

BACKGROUND: The double-stapling technique (DST) for esophagojejunostomy using the transorally inserted anvil (OrVil; Covidien Japan, Tokyo, Japan) is one of the reconstruction methods used after laparoscopy-assisted total gastrectomy (LATG). This technique has potential advantages in terms of less invasive surgery without the need to create a complicated intraabdominal anastomosis. METHODS: From 2008 to 2011, 262 patients with gastric cancer underwent total gastrectomy and reconstruction with a Roux-en-Y anastomosis, and 52 patients underwent LATG with DST. A retrospective analysis then was performed comparing the patients who experienced postoperative stenosis after LATG-DST (positive group) and the patients who did not (negative group). A comparative analysis was performed among patients comparing conventional open total gastrectomy and LATG, and multivariate analysis was performed to evaluate risk factors for the development of anastomotic stenosis. RESULTS: A minor leak was found in 1 patient (1.9 %), and 11 patients experienced anastomotic stenosis (21 %) after LATG with DST. Among the patients with anastomotic stenosis, three (3/4, 75 %) anastomoses were performed with the 21-mm end-to-end anastomosis (EEA) stapler, and eight anastomoses were performed (8/47, 17 %) with the 25-mm EEA stapler. The median interval to the diagnosis of anastomotic stenosis was 43 days after surgery. The patients with stenosis needed endoscopic balloon dilation an average of four times, and the rate of perforation after dilation was 13 %. The clinical and operative characteristics did not differ between the two groups. Anastomotic stenosis after open total gastrectomy occurred in two cases (0.98 %). Multivariate analysis showed that the size of the EEA stapler and the use of DST were risk factors for anastomotic stenosis. CONCLUSION: Esophagojejunostomy using DST with OrVil is useful in performing a minimally invasive procedure but carries a high risk of anastomotic stenosis.

BACKGROUND: Some hospitals lack facilities for radioisotopes in sentinel node biopsy. A novel method is used with a superparamagnetic tracer and a magnetometer instead of a radioisotope. METHODS: Thirty patients were included in the study after obtaining IRB approval. Superparamagnetic iron oxide and patent blue dye were injected in the subareolar breast tissue. Following a few minutes of massage to promote migration of the iron tracer and blue dye throughout the lymphatic vessels, the axillary lymph nodes were detected transdermally using a handheld magnetometer and followed by standard axillary dissection in all patients. RESULTS: Of 30 patients evaluated, sentinel lymph nodes were identified in 90% (27/30) using both blue dye and magnetic tracer. Sentinel lymph nodes were identified using the magnetic method in 23/30 (77%) and blue dye in 24/30 (80%). There was one false-negative sentinel node, resulting in an overall sensitivity of 6/7 (86%). CONCLUSIONS: This is the first study to use a magnetic tracer to identify sentinel lymph nodes in patients with breast cancer. This new technique may alter the role of radioisotopes with further refinement and experience.

We report a case of acquired hemophilia A (AHA) after esophageal resection. The patient was an 80-year-old woman whose preoperative activated partial-thromboplastin time (APTT) was well within the normal range, at 34.9 s. She underwent thoracic esophagectomy and gastric pull-up for superficial esophageal cancer (operative time, 315 min; intraoperative blood loss, 245 ml). Intrathoracic and subcutaneous bleeding occurred spontaneously on postoperative day (POD) 39. The APTT was prolonged, at 140 s, and factor VIII inhibitor was 36 Bethesda U/ml. Treatment with recombinant activated factor VII, prednisolone, and cyclophosphamide resulted in remission within 2 months. This case supports an association between surgery and the triggering of factor VIII inhibitors. The diagnosis of AHA requires clinical acumen and must be considered in any patient with bleeding and a prolonged APTT.

We report on a 53-year-old male with esophageal cancer. He had no evidence of distant metastasis, and received a subtotal esophagectomy. Histopathologically, the tumors were contiguous with Barrett's epithelium. Undifferentiated carcinoma components existed independently of differentiated adenocarcinoma components. Undifferentiated carcinoma was present proximal to the esophagogastric junction. Both tumors had invaded the submucosa and were associated with a prominent lymphoid stroma. Metastasis from undifferentiated carcinoma was found in the paraesophageal lymph nodes. Immunohistochemically, both components were negative for 34bE12 and positive for CAM5.2 and showed nearly identical staining patterns for p53, indicating that the tumors were derived from Barrett's epithelium. Because the undifferentiated carcinoma did not express CK20 or carcinoembryonic antigen, the properties of adenocarcinoma had apparently been lost during the process of tumor cell progression. This is the first report of undifferentiated carcinoma associated with Barrett's esophagus with adenocarcinoma.

BACKGROUND: Lynch syndrome, also referred to as hereditary nonpolyposis colorectal cancer, is the most common form of hereditary colorectal cancer, and is associated with a high incidence of multiple primary neoplasms in various organs. METHODS: A 79-year-old woman (patient 1) diagnosed with ascending colon cancer had a history of previous carcinomas of the uterus, stomach, uroepithelial tract, and colon. One year later, she developed a brain tumor (glioblastoma). A 54-year-old female (patient 2) was diagnosed with endometrial cancer and sigmoid colon cancer. Both patients underwent genetic evaluations independently. RESULTS: No mutations were found in an exon-by-exon analysis of genomic DNA by polymerase chain reaction (PCR) and reverse transcription (RT)-PCR. However, multiplex ligation-dependent probe amplification (MLPA) identified genomic duplication spanning from exon 7 to exon 14 of the MSH2 gene in both patients. Due to the presence of this characteristic gene duplication, their pedigrees were investigated further, and these showed that they are paternal half-sisters, consistent with paternal inheritance. CONCLUSION: Large genomic duplication from intron 6 through intron 14 in MSH2 is a very rare cause of Lynch syndrome and is difficult to identify with conventional methods. MLPA may be an alternative approach for detecting large-scale genomic rearrangements.

We present three patients with T2 acinar cell carcinomas (ACC) (two of which were small) and discuss their clinical and pathological features. Case 1: A 34 year-old woman had a 2.6 cm iso- or hyperdense tumor. Enucleation was performed but final diagnosis was ACC and a pylorus preserving pancreaticoduodenectomy was performed. Case 2: A 35 year-old woman was found to have a 4.5 cm hypervascular tumor in the tail of the pancreas. Distal pancreatectomy was performed. Case 3: A 61 year-old man suffered from acute pancreatitis and was found to have an encapsulated 2.5 cm hypervascular tumor in the head of pancreas. Pylorus-preserving pancreaticoduodenectomy was performed. These three patients with T2 ACCs had common characteristics including well-demarcated exophytic tumors with slow and limited progress, distinctively different from large ACCs and pancreatic ductal adenocarcinomas. ACCs are important in the differential diagnosis of homogeneously or heterogeneously enhancing small pancreatic tumors. Copyright (c) 2013, IAP and EPC. Published by Elsevier India, a division of Reed Elsevier India Pvt. Ltd. All rights reserved.

OBJECTIVE: The Lichtenstein inguinal hernia repair is commonly performed and suitable for teaching basic surgical skills. The objective of this study is to evaluate the feasibility of this procedure for surgical training, particularly in regard to patient outcomes. DESIGN: Retrospective case review after introduction of an integrated teaching program. SETTING: University teaching hospital. PARTICIPANTS: The Lichtenstein inguinal hernia repair is the standard procedure for adult primary unilateral inguinal hernia since 2003 at Jichi Medical University. We introduced an integrated teaching system of lectures, skill training, and videos to teach the skills for Lichtenstein inguinal hernia repair to residents and junior faculty in 2003. Cases were retrospectively divided into 4 groups. based on the experience of the operating surgeon; junior residents (PGY 1-2, group A), senior residents (PGY 3-5, group B), junior faculty (PGY 6-10, group C), and senior faculty (PGY 11 or more, group D). Background, perioperative factors, and outcomes were evaluated among the groups. RESULTS: A total of 246 elective inguinal hernia repairs (group A: 136, group B: 49, group C: 42, group D: 19) were performed. There was a significant difference in the frequeney of concomitant diseases (p = 0.012) and anticoagulant therapy (p = 0.031). Average operating time was 80.7 +/- 24.9, 72.6 +/- 20.8, 63.5 +/- 22.0, and 54.7 +/- 27.9 (min +/- SD) in groups A, B, C, and D, respectively, with a significant difference between groups A and D (p &lt; 0.001). No significant differences were observed in estimated blood loss (p = 0.216) or morbidity (p = 0.294). CONCLUSIONS: The Lichtenstein inguinal hernia repair can be safely performed by residents and junior faculty with the appropriate supervision of senior faculty without any disadvantage to patients. This integrated teaching program for Lichtenstein inguinal hernia repair is effective and feasible for training residents and junior faculty. (J Surg 69:605-610. (C) 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

OBJECTIVE: Adenosquamous carcinoma originating in the stomach is an unusual neoplasm with few existing histological studies. This study was aimed to gain insight into the histogenetic and clinicopathological characteristics of gastric cancer with squamous cell carcinoma (SCC) components. METHODS: From January 2001 to June 2010 a total of 1735 patients underwent a resection of gastric cancer. Histopathologically, eight patients had adenocarcinoma containing SCC components, in which the proportion of SCC components was above 25% of the total tumor mass in four patients. The immunohistochemical and clinicopathological characteristics of these eight patients were analyzed. RESULTS: The median survival duration was 22 months. Adenocarcinoma was present at the superficial layer of all tumors and SCC was primarily present at sites with deep invasion. Immunohistochemically, adenocarcinoma components were positive for cytokeratin (CK) 8/18/19 and CK7 in all cases. SCC components were positive for carcinoembryonic antigen and CK7 in more than 60% of patients. Expression patterns of p53 product were identical in both components. SCC components were positive for 34βE12 and adenocarcinoma components were negative for 34βE12 in all patients. CONCLUSIONS: SCC components are derived from squamous metaplasia in a pre-existing adenocarcinoma. A gastric adenocarcinoma with SCC components is associated with various patterns of metastasis and both SCC and adenocarcinoma components have the potential for metastasis. Gastric cancer with SCC components is a clinically aggressive tumor.

Strangulation of the gallbladder by the omentum is extremely rare. We report what to our knowledge is only the second documented case of strangulation of a floating gallbladder by the lesser omentum. A 61-year-old Japanese woman presented to a local hospital after the sudden onset right upper quadrant pain. Her clinical features suggested a gallbladder volvulus, and the patient was referred to our hospital for investigation and treatment. Ultrasonography and computed tomography showed no cholecystolithiasis, but the fundus and body of the gallbladder were markedly swollen without wall thickening, whereas the neck of the gallbladder was normal. A narrowed, twisted area was seen between the body and neck of the gallbladder. Based on these findings, gallbladder volvulus was diagnosed and she underwent emergency laparoscopic cholecystectomy. The fundus and body of the gallbladder were grossly necrotic. The narrowest part of the gallbladder was tightly strangulated by the lesser omentum, but the gallbladder neck was normal. Histopathologic examination of the resected gallbladder showed ischemic changes in the wall of the fundus and body. This case highlights that the clinical features and imaging findings of a gallbladder strangulated by the lesser omentum are similar to those of gallbladder volvulus and that a positive outcome is dependent on a correct diagnosis and prompt surgical management.

INTRODUCTION: Laparoscopic splenectomy using pneumoperitoneum has been performed since 1992. The gasless abdominal wall-lifting method for laparoscopic splenectomy was introduced as an alternative. This retrospective study was undertaken to compare results using the two techniques. METHODS: Between 1995 and 2010, 54 patients underwent laparoscopic splenectomy at a single institution; 30 underwent the procedure using the gasless technique and 24 using pneumoperitoneum. There were no significant differences between the two groups regarding age, sex or BMI, but more patients underwent concurrent operations in the pneumoperitoneum group. The abdominal wall-lift system with subcutaneous K-wires was used for the gasless method. RESULTS: Intraoperative blood loss was similar in the two groups (193.0 ± 196.7 mL gasless, 217.3 ± 296.6 mL pneumoperitoneum; P > 0.05), but operative time (182.1 ± 92.1 min, 135.1 ± 46.1 min; P < 0.05), and resected spleen weight (306.1 ± 297.7 g, 138 ± 81.0 g; P < 0.05) were significantly different. In the gasless group, additional procedures included conversion (n = 1), mini-laparotomy (n = 2), and CO(2) insufflation (n = 2). Excluding the concurrent living-related kidney donor patients, hospital stay was similar (6.9 ± 2.5 days, 6.3 ± 2.0 days, P > 0.05). CONCLUSION: Although gasless laparoscopic splenectomy is feasible, there are disadvantages, particularly the restricted operative working space in some patients. These results suggest that either technique may be used on an individual basis in patients undergoing laparoscopic splenectomy.

OBJECTIVE: Although studies have been conducted to identify factors that attract students to a career in surgery, the relative importance of factors that attract students to a particular training program remains unknown. Comparative data between countries may provide insights and ultimately provide guidance to program directors as they seek to attract the best applicants to their program. DESIGN: Blinded written survey, scored 1-5 on a list of 26 factors divided into 3 categories, including educational factors, lifestyle factors, and other. SETTING: Jichi Medical University, Japan and the David Geffen School of Medicine at University of California Los Angeles. PARTICIPANTS: Japan residents (N = 125), Japan Medical Students (N = 68), United States Residents (N = 99), and United States Students (N = 55). RESULTS: All 4 groups surveyed judged faculty quality among the most important factors, with educational program quality, clinical experience and perceptions of resident happiness also rated among the most important. A comparison of factors consistent with lifestyle and factors consistent with the educational program found significantly (p &lt; 0.05) higher scores for educational factors by 3 groups surveyed. CONCLUSIONS: Resident applicants are most interested in training program factors related to the quality of the educational program and the faculty. Issues such as salary, vacation, night call, location, or benefits are considered less important. The results in Japan and the United States were remarkably similar despite major differences in the educational system and debt load at the time of graduation. Program directors should communicate the value of those factors considered important by applicants as part of the recruitment process. (J Surg 69: 167-172. (C) 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

BACKGROUND: Among the more common human malignancies, invasive ductal carcinoma of the pancreas has the worst prognosis. The poor outcome seems to be attributable to difficulty in early detection. METHODS: We compared the plasma protein profiles of 112 pancreatic cancer patients with those of 103 sex- and age-matched healthy controls (Cohort 1) using a newly developed matrix-assisted laser desorption/ionization (oMALDI) QqTOF (quadrupole time-of-flight) mass spectrometry (MS) system. RESULTS: We found that hemi-truncated apolipoprotein AII dimer (ApoAII-2; 17252 m/z), unglycosylated apolipoprotein CIII (ApoCIII-0; 8766 m/z), and their summed value were significantly decreased in the pancreatic cancer patients [P = 1.36×10(-21), P = 4.35×10(-14), and P = 1.83×10(-24) (Mann-Whitney U-test); area-under-curve values of 0.877, 0.798, and 0.903, respectively]. The significance was further validated in a total of 1099 plasma/serum samples, consisting of 2 retrospective cohorts [Cohort 2 (n = 103) and Cohort 3 (n = 163)] and a prospective cohort [Cohort 4 (n = 833)] collected from 8 medical institutions in Japan and Germany. CONCLUSIONS: We have constructed a robust quantitative MS profiling system and used it to validate alterations of modified apolipoproteins in multiple cohorts of patients with pancreatic cancer.

INTRODUCTION: Uterine rupture is a life-threatening condition both to mothers and fetuses. Its early diagnosis and treatment may save their lives. Previous myomectomy is a high risk factor for uterine rupture. Intestinal adhesion due to previous myomectomy may also prevent early diagnosis of uterine rupture. CASE PRESENTATION: A 38-year-old primiparous non-laboring Japanese woman with a history of myomectomy was admitted in her 34th week due to lower abdominal pain. Although the pain was slight and her vital signs were stable, computed tomography revealed massive fluid collection in her abdominal cavity, which led us to perform a laparotomy. Uterine rupture had occurred at the site of the previous myomectomy; however, the small intestine was adhered tightly to the rupture, thus masking it. The baby was delivered through a low uterine segment transverse incision. The ruptured uterine wall was reconstructed. CONCLUSION: Intestinal adhesion due to a prior myomectomy occluded a uterine rupture, possibly masking its symptoms and signs, which may have prevented early diagnosis.

BACKGROUND: To decrease the incidence of internal hernia after laparoscopic gastric bypass, current recommendations include closure of mesenteric defects. Laparoscopic gastric resection is used increasingly for the treatment of gastric cancer, but the incidence of internal hernia in the treated patients has not been studied. METHODS: This study retrospectively reviewed 173 patients who underwent laparoscopic resection for gastric cancer at one institution, including distal and total gastric resections with antecolic Roux-en-Y reconstruction. RESULTS: An internal hernia occurred in 4 (7%) of 58 patients whose jejunojejunal mesenteric defect was not closed a mean of 326 days after surgery. All the patients underwent reoperation with reduction and repair of the hernia. In 115 subsequent cases, with closure of the mesenteric defect, internal hernias did not occur (0/115 cases; p < 0.05). CONCLUSION: Based on the current recommendations for patients undergoing bariatric surgery, closure of this potential hernia defect is mandatory after laparoscopic gastrectomy with a Roux-en-Y reconstruction for gastric cancer.

BACKGROUND: The aim of this study was to identify a new plasma biomarker for use in early detection of colorectal cancer. METHODS: Using the combination of hollow fiber membrane (HFM)-based low-molecular weight protein enrichment and two-dimensional image converted analysis of liquid chromatography and mass spectrometry (2DICAL), we compared the plasma proteome of 22 colorectal cancer patients with those of 21 healthy controls. An identified biomarker candidate was then validated in two larger cohorts [validation-1 (n = 210) and validation-2 (n = 113)] using a high-density reverse-phase protein microarray. RESULTS: From a total of 53,009 mass peaks, we identified 103 with an area under curve (AUC) value of 0.80 or higher that could distinguish cancer patients from healthy controls. A peak that increased in colorectal cancer patients, with an AUC of 0.81 and P value of 0.0004 (Mann-Whitney U test), was identified as a product of the PLIN2 gene [also known as perilipin-2, adipose differentiation-related protein (ADRP), or adipophilin]. An increase in plasma adipophilin was consistently observed in colorectal cancer patients, including those with stage I or stage II disease (P < 0.0001, Welch's t test). Immunohistochemical analysis revealed that adipophilin is expressed primarily in the basal sides of colorectal cancer cells forming polarized tubular structures, and that it is absent from adjacent normal intestinal mucosae. CONCLUSIONS: Adipophilin is a plasma biomarker potentially useful for the detection of early-stage colorectal cancer. IMPACT: The combination of HFM and 2DICAL enables the comprehensive analysis of plasma proteins and is ideal for use in all biomarker discovery studies.

We report two cases of carcinoid tumor of the gallbladder. Case 1 was a 59-year-old woman who presented with epigastric pain. Abdominal ultrasonography and computed tomography (CT) revealed a 16 mm polypoid lesion in the neck of the gallbladder. Tumor markers were within normal limits. Open cholecystectomy was performed with a preoperative diagnosis of early cancer of the gallbladder. Case 2 was a 45-year-old man. A polyp in the gallbladder was incidentally detected on annual checkup. Ultrasound and CT showed an 18 mm protruding lesion in the neck of the gallbladder. Laparoscopic cholecystectomy was performed and the tumor diagnosed as a carcinoid tumor based on the findings of funicular and tubular cells in the lamina propria mucosa, homogeneous nuclei, basophilic cytoplasm, and positive staining with chromogranin A and synaptophysin. The postoperative course of both patients was uneventful, with no recurrence at 44 and 41 months after surgery. In this literature review of 39 cases, classical carcinoid of the gallbladder has a favorable postoperative outcome. Of cases reviewed, 60% are located in the neck of the gallbladder and 50% have a polypoid shape.

The patient is a 61-year-old man who had previously undergone an extended thymectomy for myasthenia gravis. Endoscopic examination during a routine follow-up visit revealed early gastric cancer in the proximal portion of the stomach. To undergo resection the patient received general and epidural anesthesia. The conditions were unfavorable for laparoscopic-assisted surgery because he had a body mass index of 33 and muscle relaxants could not be used. Pneumoperitoneum was induced with carbon dioxide, and the abdominal wall was lifted. An adequate working space was secured in the upper abdomen and proximal gastrectomy was successfully performed.

BACKGROUND: Esophagectomy after gastric reconstruction leads to significant weight loss. Ghrelin is known to stimulate appetite and cause weight increase. The objective of this study is to examine the relationship of serum ghrelin levels and weight loss in patients after esophagectomy for cancer. METHODS: Twenty-two patients underwent esophagectomy including gastric reconstruction. Serum ghrelin levels and weight were measured preoperatively and then postoperatively for 12 months in all patients. A questionnaire assessed appetite, amount of food eaten, satisfaction, and frequency of eating. RESULTS: Preoperatively, the mean serum ghrelin level was 67.9 ± 42.6 (fmol/mL ± SD), and at 1, 3, 6, and 12 months after surgery were 43.4 ± 28.1, 51.5 ± 32.2, 67.1 ± 50.9, and 84.9 ± 43.1, respectively. Compared with preoperative values, the mean body mass index decreased by 1.9 ± 1.5, 2.3 ± 1.8, 2.1 ± 2.3, 2.4 ± 2.7 at 1, 3, 6, and 12 months after surgery. While appetite score showed a decrease at 1 month (1.6 ± 0.92), appetite increased by 12 months postoperatively (2.7 ± 1.0) and showed a strong positive correlation (r = 0.743) with serum ghrelin levels. There were no significant differences in ghrelin levels when patients were stratified by disease stage, recurrence, or administration of adjuvant chemotherapy. CONCLUSIONS: Esophagectomy resulted in temporary reduction of ghrelin levels, but while levels returned to normal 3 months later, weight loss persisted at 12 months. Further study is needed to elucidate the mechanisms of persistent weight loss and design therapeutic interventions to recover the weight lost.

The development of a new plasma biomarker for early detection would be necessary to improve the overall outcome of colorectal cancer. Here we report the identification and validation of the ninth component of complement (C9) as a novel plasma biomarker for colorectal cancer by cutting-edge proteomic technologies. Plasma proteins were enzymatically digested into a large array of peptides, and the relative quantity of a total of 94,803 peptide peaks was compared between 31 colorectal cancer patients and 59 age/sex-matched healthy controls using 2D image-converted analysis of liquid chromatography and mass spectrometry. The selected biomarker candidates were validated in 345 subjects (115 colorectal cancer patients and 230 age/sex-matched healthy controls) using high-density reverse-phase protein microarrays. Plasma levels of Apo AI and C9 in colorectal cancer patients significantly differed from healthy controls with P values of 7.94×10(-4) and 1.43×10(-12) (Student's t-test), respectively. In particular, C9 was elevated in patients with colorectal cancer, including those with stage-I and -II diseases (P=3.01×10(-3) and P=1.13×10(-5) , respectively). Although the significance of the present study must be validated in an independent clinical study, the increment of plasma C9 may be applicable to the early detection of colorectal cancer.

BACKGROUND: Early detection is essential to improve the outcome of patients with pancreatic cancer. A noninvasive and cost-effective diagnostic test using plasma/serum biomarkers would facilitate the detection of pancreatic cancer at the early stage. METHODS: Using a novel combination of hollow fiber membrane-based low-molecular-weight protein enrichment and LC-MS-based quantitative shotgun proteomics, we compared the plasma proteome between 24 patients with pancreatic cancer and 21 healthy controls (training cohort). An identified biomarker candidate was then subjected to a large blinded independent validation (n = 237, validation cohort) using a high-density reverse-phase protein microarray. RESULTS: Among a total of 53,009 MS peaks, we identified a peptide derived from CXC chemokine ligand 7 (CXCL7) that was significantly reduced in pancreatic cancer patients, showing an area under curve (AUC) value of 0.84 and a P value of 0.00005 (Mann-Whitney U test). Reduction of the CXCL7 protein was consistently observed in pancreatic cancer patients including those with stage I and II disease in the validation cohort (P < 0.0001). The plasma level of CXCL7 was independent from that of CA19-9 (Pearson's r = 0.289), and combination with CXCL7 significantly improved the AUC value of CA19-9 to 0.961 (P = 0.002). CONCLUSIONS: We identified a significant decrease of the plasma CXCL7 level in patients with pancreatic cancer, and combination of CA19-9 with CXCL7 improved the discriminatory power of the former for pancreatic cancer. IMPACT: The present findings may provide a new diagnostic option for pancreatic cancer and facilitate early detection of the disease.

We report an extremely rare case of solitary liver metastasis from papillary thyroid carcinoma. A 56-year-old woman referred for a lung-cancer screening-detected liver tumor. Her medical history included right thyroid lobectomy for papillary carcinoma 18 years earlier and total thyroidectomy for adenoma-tous goiter 2 years thereafter. Blood tests showed markedly-elevated preoperative serum thyroglobulin. Computed tomography (CT) showed a lateral hepatic tumor with a central scar and capsule-like structure. Contrast medium enhanced the lesion in the early phase, with washout in the late phase. Magnetic resonance imaging (MRI) showed lesions in the left seventh rib and first lumbar vertebra in the same phase as the liver tumor. Whole-body bone scintigraphy showed increased tracer uptake in the sixth thoracic vertebra and seventh rib, yielding a diagnosis of solitary liver tumor with multiple bone metastases. The liver tumor was suspected of being hepatocellular carcinoma and liver metastases from thyroid cancer. The liver tumor was resected concomitant to lateral segmentectomy with rib biopsy. Histo-pathologically, both lesions were papillary thyroid carcinoma metastases. © 2011 The Japanese Society of Gastroenterological Surgery.