Etsuo Hishikawa

IMPORTANCE OF POSITIVE PERITONEAL LAVAGE CYTOLOGY FINDINGS IN THE STAGE GROUPING OF GASTRIC CANCER

Although peritoneal lavage cytology is widely performed during surgery for gastric cancer and the results have been reported to be one of the accurate prognostic factors, the cancer stage is determined independent of the results of lavage cytology according to the First English Edition of Japanese Classification of Gastric Carcinoma. In this study we demonstrated the validity of lavage cytology for accurately staging gastric cancer. Between 1988 and 1996, peritoneal lavage cytology was performed in 347 patients with resectable gastric cancer. Among them, cytology was positive in 29 cases (8.4%). The survival rate of the cytology-positive patients in each stage was worse than that of all patients in the same stage. The prognosis of patients with positive cytology findings and serosa-exposed gastric cancer was significantly worse than that of negative cytology findings and serosa-exposed gastric cancer, and similar to that of negative cytology findings and serosa-infiltrating gastric cancer. Our data indicated that positive cytology findings thus indicated a poor prognosis, and the prognostic difference between positive and negative cytology findings was approximately a one-stage difference in the Japanese stage grouping. Based on our findings, the results of peritoneal lavage cytology should thus be included in the factors for staging gastric cancer.

Impact of Preoperative Serum Carcinoembryonic Antigen, CA 19-9 and Alpha Fetoprotein Levels in Gastric Cancer Patients

The relationship between preoperative serum carcinoembryonic antigen (CEA), CA 19-9 and α-fetoprotein (AFP) levels and their clinicopathological features were evaluated in gastric cancer patients. The positive rates of CEA, CA 19-9 and AFP were 24.8, 27.6 and 12.7%, respectively. Gastric cancer with deeper tumor invasion was significantly more common among patients positive for these tumor markers. Patients with positive CEA or CA 19-9 values had a significantly high risk of lymph node metastases (p = 0.045 and p = 0.002, respectively). Synchronous liver metastases was more commonly found in patients with a positive CA 19-9 value. A significant difference (p < 0.001) in survival rate was found between patients with positive CA 19-9 values and those with negative values. CA 19-9 is useful for the prognosis of gastric cancer patients, whereas CEA, although unsuitable for prognosis, contributes to the prediction of cancer invasion.

A case of gallbladder adenomyomatosis with pancreaticobiliary maljunction and an anomaly of the cystic duct joined the common channel

A 46-yr-old woman was admitted to our hospital with mild epigastric pain. Ultrasonography and computed tomography revealed an extremely thickened gallbladder wall. Endoscopic retrograde cholangiopancreatography demonstrated that the main pancreatic duct joined the nondilated common bile duct at the outer point of the duodenal wall (P-C type of pancreaticobiliary maljunction), and the cystic duct joined the common channel directly. The intraoperative amylase levels of the bile juices both in the common bile duct and the cystic duct were high. A cholecystectomy was performed. The wall of the gallbladder was markedly thick, yellowish, elastic, and soft. Histologically, Rokitansky-Aschoff sinus proliferation, hypertrophy of smooth muscles, and fibrosis were seen. The diagnosis was a generalized type of adenomyomatosis. The pathogenesis of the adenomyomatosis was believed to result from chronic stimulation as a result of pancreatic juice reflux. The etiology of this unusual type of junction was considered to be the result of the combination of pancreaticobiliary maljunction and an anomaly of lower junction of the cystic duct.

Primary malignant melanoma of the esophagus treated with heavy-ion radiotherapy.

Primary malignant melanoma of the esophagus (PMME) is an uncommon but aggressive tumor with very poor prognosis. There is no established treatment plan for the disease, which may be attributed to its rarity and aggressiveness. Surgery is the choice of treatment in early cases. Radiotherapy follows surgery, and chemotherapy has an insignificant role in its treatment. Radiation with heavy ion beams is showing promising results in cancer therapy. Compared to conventional radiation, it permits selective irradiation with minimal injury to the surrounding normal tissue, and treatment with a low dose within a short interval of time is possible. We herein report a case of PMME treated with heavy ion radiation, the first case to be reported so far, and review the relevant literature.

Evaluation of a new staging system by the Japanese Research Society for Gastric Cancer.

The feasibility of the new classification of stage grouping by the Japanese Research Society for Gastric Cancer was evaluated. During the 22-year period between January 1975 and December 1996, a total of 1294 patients with primary gastric cancer underwent laparotomy at the Department of Surgery, Chiba University; 1222 had their lesions removed during the gastrectomy and 72 remained nonresected. Cases of direct operative death totaled 17 (1.3%). Five hundred patients (38.6%) died of a relapse of the original cancer and 42 (3.2%) died of other diseases within the followup period. Six patients (0.5%) were lost during the followup. The 5-year cumulative patient survival rates of the seven stages of the new stage grouping were distinctly proportional, and the differences were also statistically significant except between stages IIIb and IVa. The two major revised points in the new stage grouping, new classification of the depth of cancer invasion, and new stage grouping by a mosaic combination of the degree of invasion and lymph node metastasis were thus found to be reasonable based on the actuarial 5-year survival rates of the subgroups in the same stage. The present study also showed that the classification of stage IV still requires further discussion.

What are the findings of esophageal cancer to be treated endoscopically

In Japan, the results of histopathologic analyses on esophageal carcinomas have shown that almost all of them are squamous epithelial cancers. The abnormal epithelium that is difficult to differentiate by endoscopy can be easily visualized by chromoendoscopy with the use of iodine staining. Since the establishment of endoscopic mucosal resection (EMR), it has been used increasingly to treat mucosal cancers. It is necessary to diagnose accurately the depth of invasion of mucosal cancer when it is to be treated by EMR. In this article, we explain our routine techniques to visualize and interpret the lesions that are candidates for EMR. It is of great benefit to detect lesions at their early stage, which leads to the most desirable endoscopic treatment.

Flicking method: A novel colonoscope insertion method for surveillance colonoscopy in ulcerative colitis patients

Aim:  Periodic surveillance colonoscopy is required for patients with ulcerative colitis to detect colitis‐associated dysplasia at an early stage. However, sometimes colonoscopy may damage the fragile mucosa of patients with ulcerative colitis. The aim of this study was to devise a new method of surveillance colonoscopy for patients with mild to moderate ulcerative colitis.

W1125 Characteristics of Esophageal Motility in Patients With NERD Refractory for PPIs and a Treatment Strategy Using Rikkunshito – A Study Using Combined Multichannel Intraluminal Impedance and Manometry (MII-EM): Part II

Background: More than 50% of non-erosive gastroesophageal reflux disease (NERD) patients have a poor response to proton pump inhibitors (PPIs) treatment. Recently, it was reported that esophageal motility disorder involving a decline in esophageal clearance contributes to refractory for PPIs. However, there was few reports focused to esophageal motility of patients with NERD refractory for PPIs and there is no established strategy for treatment of refractory NERD. Aims: To clarify the characteristic of patients with refractory NERD, we investigated the esophageal function using MII-EM. In addition, we also evaluated the efficacy of rikkunshito which is a gastrointestinal prokinetic agent. Methods: In this study, 24 NERD patients including 15 patients with NERD refractory for PPIs treatment. Refractory NERD was defined as a score of more than 6 points in the QUEST questionnaire after PPI treatment for over than 4 weeks. After wash-out of gastrointestinal-related drugs, all enrolled patients underwent the examinations using MII-EM and then started oral administration of rikkunshito (7.5 g/ day). After rikkunshito treatment for 8 weeks, the examinations using MII-EM was performed again. Also, symptoms were assessed using the Gastrointestinal Symptom Rating Scale (GSRS) before and 4 weeks / 8 weeks after starting the rikkunshito treatment. Results: At first examination using MII-EM, 71.4% of the refractory NERD patients had peristaltic contraction rate (PC rate) deviating from the standard value (≧80%) and 85.7% of them had a complete bolus transit rate (CBT rate) deviating from the standard value (≧75%). On the other hand, in the 9 patients other than the refractory NERD, the rate of patients with such deviation was 25.0% and 50.0%, respectively. The rate of patients with a resting LES pressure deviating from the standard value was comparable between the two patient groups. Next, we also evaluated the efficacy of rikkunshito in the refractory NERD. Rikkunshito significantly improved the LES residual pressure during swallow from 7.2 ± 5.1 mmHg to 5.2 ± 4.1 mmHg, PC rate from 52.4 ± 34.6% to 75.5 ± 31.1% and CBT rate from 51.5 ± 27.4% to 81.8 ± 16.0%. In assesment of symptoms with GSRS, rikkunshito significantly improved score of acid reflux symptoms, dyspepsia-like symptoms and total gastrointestinal symptoms. Conclusion: These results suggested that the refractory NERD patients had a disorder of esophageal motility and that rikkunshito ameliorated the gastrointestinal symptoms through improvement of the esophageal and LES motility disorder. We propose the application of rikkunshito as a strategy to treat patients with NERD refractory for PPIs.

M1876 Rikkunshito Improves Esophageal Motility Disorder and Symptoms in Patients with NERD - a Study Using Combined Multichannel Intraluminal Impedance and Manometry (MII-EM) -

Background: Proton pump inhibitors (PPI) are the drug of first choice for treating patients with gastroesophageal reflux disease (GERD). However, about 50% of non-erosive reflux disease (NERD) patients have a poor response to PPI treatment. It is reported that esophageal motility disorder involving a decline in esophageal clearance contributes to the poor PPI response. Accordingly, a drug capable of enhancing esophageal motility would be beneficial in the treatment of NERD patients. Rikkunshito, a gastrointestinal prokinetic agent, is known to improve esophageal clearance in GERD patients and gastric emptying in functional dyspepsia patients and to increase secretion of ghrelin in rats. Aim: To clarify the efficacy of rikkunshito in NERD patients, we evaluated the effects of rikkunshito on esophageal and lower esophageal sphincter (LES) motility and symptoms. Methods: Fifteen patients were enrolled in the study. They were diagnosed as having NERD according to endoscopic testing and the score (6 points or more) obtained on the questionnaire for the diagnosis of reflux disease (QUEST). All patients stopped taking all gastrointestinal-related drugs for over 1 week prior to rikkunshito treatment, and were administered rikkunshito (7.5 g per day, orally) for 8 weeks. Esophageal and LES functions during liquid or semisolid swallow were evaluated using MII-EM following gold standard methods before and after rikkunshitotreatment. Symptoms were assessed using the Gastrointestinal Symptom Rating Scale (GSRS) before, 4 weeks after, and 8 weeks after treatment. Results: Rikkunshito-treatment significantly improved the mean of complete bolus transit (CBT) during liquid or semisolid swallow from 60.7±7.7% to 90.0±5.8% (p 79%, semisolid: >69%) for CBT decreased from 53.3% to 16.7% and from 60.0% to 33.3% after treatment, respectively. In manometry evaluation, rikkunshito significantly improved the mean of LES residual pressure during liquid swallow from 6.0±1.3 mmHg to 3.8±1.4 mmHg (p<0.05). In addition, rikkunshito significantly ameliorated total GI symptom scores in GSRS (from 2.1±0.2 to 1.6±0.1: (p<0.05)) and showed a tendency toward improvement of subscales for reflux symptoms, abdominal pain and dyspeptic symptoms. Conclusion: We found that rikkunshito improved the esophageal clearance and symptoms in NERD patients through the amelioration of esophageal and LES motility disorder. Thus, rikkunshito may become a useful drug for treating NERD patients.