Hirofumi Ichikawa

Probiotic bacteria stimulate gut epithelial cell proliferation in rat.

Probiotics are used for various intestinaldiseases. However, their effects on gut epithelial cellproliferation have not been investigated. Weadministered 107 colony-forming units ofLactobacillus casei or Clostridium butyricum , or no probiotics(control) by gastric intubation once a day for sevendays to rats fed an elemental diet. We estimated thecrypt cell production rate of the jejunum, ileum, cecum, and distal colon. We also quantified cecalbacteria. Both probiotics increased the crypt cellproduction rate of the jejunum and ileum by 25-40%, ofthe cecum by 70%, and of the distal colon by more than 200% compared with control. Only minor variancein the cecal bacterial composition existed among thethree groups. Probiotics enhanced gut epithelial cellproliferation in rats fed an elemental diet.

Prospective Comparison of Surgery Alone and Chemoradiotherapy With Selective Surgery in Resectable Squamous Cell Carcinoma of the Esophagus

PURPOSE Esophagectomy remains the mainstay treatment for esophageal cancer, although retrospective studies have suggested that chemoradiotherapy (CRT) is as effective as surgery. To determine whether CRT can substitute for surgery as the primary treatment modality, we performed a prospective direct comparison of outcomes after treatment in patients with resectable esophageal cancer who had received CRT and those who had undergone surgery. METHODS AND MATERIALS Eligible patients had resectable T1-3N0-1M0 thoracic esophageal cancer. After the surgeon explained the treatments in detail, the patients selected either CRT (CRT group) or surgery (OP group). The CRT course consisted of two cycles of cisplatin and fluorouracil with split-course concurrent radiotherapy of 60Gy in 30 fractions. Patients with progressive disease during CRT and/or with persistent or recurrent disease after CRT underwent salvage resection. RESULTS Of 99 eligible patients with squamous cell carcinoma registered between January 2001 and December 2005, 51 selected CRT and 48 selected surgery. Of the patients in the CRT group, 13 (25.5%) underwent esophagectomy as salvage therapy. The 3- and 5-year survival rates were 78.3% and 75.7%, respectively, in the CRT group compared with 56.9% and 50.9%, respectively, in the OP group (p = 0.0169). Patients in the OP group had significantly more metastatic recurrence than those in the CRT group. CONCLUSIONS Treatment outcomes among patients with resectable thoracic esophageal squamous cell carcinoma were comparable or superior after CRT (with salvage therapy if needed) to outcomes after surgery alone.

Bronchial Artery Anatomy: Preoperative 3D Simulation with Multidetector CT

PURPOSE To preoperatively evaluate anatomic variations of the bronchial arteries by obtaining three-dimensional (3D) simulations with multidetector computed tomography (CT). MATERIALS AND METHODS This study was approved by the institutional review board, and written informed consent was obtained from all participants. Seventy-three consecutive patients with esophageal cancer underwent dynamic multidetector CT. The data were used to generate 3D simulations of the thoracic cavity. These images were then used to evaluate anatomic variations of the bilateral bronchial arteries and the mediastinal course in relation to the esophagus and trachea-bronchi. The preoperative CT findings were correlated with the thoracoscopic findings. RESULTS CT depicted 118 right bronchial and 105 left bronchial arteries. The right bronchial arteries arose from the intercostal-bronchial trunk (IBT), thoracic aorta, common trunk of both bronchial arteries (CTB), and right subclavian artery in 61, 15, 38, and four cases, respectively, whereas the left bronchial arteries arose from the thoracic aorta, IBT, and CTB in 63, four, and 38 cases, respectively. The right bronchial arteries followed preferential courses through the mediastinum, depending on the parent artery: All 61 right bronchial arteries that arose from the IBT ran along the right side of the esophagus, dorsal to the trachea-main bronchi, whereas the majority of direct-origin and CTB-type right bronchial arteries and all left bronchial arteries ran along the left side of the esophagus. During right thoracoscopy, all bronchial arteries coursing along the right side of the esophagus were identified, whereas those coursing along the left side of the esophagus were frequently out of intraoperative view. Six small right bronchial arteries that were not detected at CT were discovered during surgery. CONCLUSION Three-dimensional simulation with multidetector CT yields precise preoperative information regarding the anatomy of the bronchial arteries and their variants.

Gastric or rectal instillation of short-chain fatty acids stimulates epithelial cell proliferation of small and large intestine in rats.

Short-chain fatty acids stimulate gut epithelial cell proliferation in vivo, although the difference between oral and rectal routes is unknown. Accordingly, we examined the effect of oral or rectal administration of these acids. We instilled a mixture of acetic acid, propionic acid, and n-butyric acid (150, 60, and 60 mmol/liter, respectively; pH 6.5) or saline (270 mM, pH 6.5) into the stomach (2 ml) or rectum (1 ml) three times daily for five days in rats fed an elemental diet. We measured crypt cell production rate of the jejunum, ileum, and distal colon of these rats. The crypt cell production rate of these segments was higher in rats with gastric or rectal instillation of short-chain fatty acids than in saline controls. The rectal route was slightly more effective than the gastric route. The above results indicated that the instillation of short-chain fatty acids orally or rectally stimulated gut epithelial cell proliferation.

Effect of L-Lactic Acid, Short-Chain Fatty Acids, and pH in Cecal Infusate on Morphometric and Cell Kinetic Parameters of Rat Cecum

We studied the influences of cecal infusion ofNaCl, short-chain fatty acids (SCFA), and L-lactic acidat pH 5.0 or 7.0 for seven days on morphometric and cellkinetic parameters of the rat cecum. SCFA increased relative weight of the mucosa andsubmucosa, crypt size, and mitotic index in the cecum.L-Lactic acid stimulated mitosis only at pH 5.0. Cryptsize correlated positively to epithelial proliferative activity only when NaCl or L-lactic acid wasinfused. SCFA should have changed the balance betweenproduction and loss of the cecal epithelial cells. Theinfusate pH by itself had no effect, but modified the effects of SCFA and L-lactic acid indifferent ways. Crypt size correlated positively to thelogarithm of daily proton load of infusates. The aboveresults indicate that epithelial cell proliferation in the cecum is influenced by both SCFA andL-lactic acid, although differently, and by protonload.

Esophagectomy using a thoracoscopic approach with an open laparotomic or hand-assisted laparoscopic abdominal stage for esophageal cancer: analysis of survival and prognostic factors in 315 patients.

&NA;Survival and prognostic factors were analyzed in 315 patients with esophageal cancer undergoing thoracoscopic-assisted esophagectomy (TAE). The 5-year survival rate of 57.8% was satisfactory, indicating the oncological feasibility of TAE. Perioperative outcomes affected overall survival in the whole cohort but not in the subgroup treated with 2 endoscopic stages. Objective:To estimate the oncological feasibility of thoracoscopic-assisted esophagectomy (TAE) for esophageal cancer and to clarify the prognostic impact of perioperative factors after TAE. Background:Favorable perioperative outcomes of TAE versus open surgery have been demonstrated. However, survival data after TAE in a large cohort are limited, and no information on the prognostic influence of perioperative factors after TAE is available. Methods:Prospectively collected data for 315 patients undergoing TAE for esophageal cancer were analyzed. Survival was compared with the Kaplan-Meier analysis and Cox regression analysis between 2 surgical approaches: thoracoscopic and hand-assisted laparoscopic esophagectomy (THLE) and thoracoscopic and open laparotomic esophagectomy (TOE). Factors affecting overall survival were identified with Cox multivariate regression analysis in the whole cohort and the THLE subgroup. Results:THLE and TOE were performed in 153 and 162 patients, respectively. The overall 5-year survival of the whole cohort was 57.8%, with no difference between the THLE and the TOE group. Multivariate analysis of the 315 patients identified the following prognostic factors: blood loss, blood transfusion, intensive care unit stay, cardiovascular complications, pathological T and N stages, lymphatic invasion, intramural metastasis, and number of metastatic nodes. In the THLE subgroup, cerebral comorbidity, histological subtype, pathological T stage, and number of metastatic nodes were independent prognostic factors. Conclusions:TAE was oncologically feasible. Perioperative factors affected survival in the whole cohort, but did not in the THLE subgroup. However, the reduced perioperative factor effect in this subgroup would be small because the survival rates of the 2 surgical approaches were equal.

Thoracic Duct Visualization: Combined Use of Multidetector-row Computed Tomography and Magnetic Resonance Imaging

Purpose: The objective of the study was to assess the ability of magnetic resonance imaging (MRI) and helical multidetector-row computed tomography (MDCT) to visualize the thoracic duct in esophageal cancer patients. Methods: Sixty esophageal cancer patients underwent preoperative MDCT and MRI using 3-dimensional balanced turbo-field-echo sequence. The visualization grades by MDCT, MRI, and a combination of MDCT and MRI were scored in 4 segments of the thoracic duct (cervical, upper, middle, and lower). Results: In the cervical, middle, and lower segments, MRI provided significantly higher visualization grades than MDCT. In all segments, combined MDCT and MRI resulted in higher grades than MDCT alone. In addition, combined MDCT and MRI successfully allowed visualization of the cervical, upper, middle, and lower segments of the thoracic duct in 46 (76.7%), 50 (83.3%), 58 (96.7%), and 60 (100%) patients, respectively. Conclusions: Combination of MDCT and MRI allows noninvasive thoracic duct visualization, providing 3-dimensional information on other thoracic structures.

Virtual CT thoracoscopy : preoperative simulation for thoracoscopic surgery of esophageal cancer

Thoracoscopic esophageal surgery is a complex procedure requiring simultaneous dissection of the esophagus and lymph nodes while maintaining the surrounding vessels. Because of the difficulty in obtaining comprehensive views of the operative field, three-dimensional (3-D) images with preoperative information on the vascular system, esophagus, trachea, lungs, lymph nodes, skin, and bones would be extremely helpful in performing the surgery.

Three-dimensional lymphoscintigraphy using SPECT/CT and 123I-BMIPP for the preoperative detection of anatomical anomalies of the thoracic duct.

Purpose Orally administered 123I-labeled 15-(4-iodophenyl)-3(R,S)-methylpentadecanoic acid (BMIPP), a fatty acid analog, is absorbed from the intestine and ascends to the venous angle through the thoracic duct (TD). The objective of this study was to evaluate the clinical feasibility of 3-dimensional (3D) TD scintigraphy using SPECT/CT and BMIPP for the detection of anatomical anomalies of TD. Patients and Methods This study included 35 consecutive patients with esophageal cancer who underwent tumor resection after TD scintigraphy. For scintigraphy, 111 MBq of BMIPP was orally administered, and static images and SPECT/CT images were obtained. On the basis of the SPECT/CT fusion images, TD was divided into the following 4 segments: cervical, upper thoracic, middle thoracic, and lower thoracic. The TD visualization was categorized into 5 grades, from grade 1 (poor) to 5 (excellent). In addition, the diagnostic accuracy of 3D TD scintigraphy for the detection of anatomical anomalies of TD was calculated using the intraoperative finding as a criterion standard. Results The TD visualization grades for the cervical, upper, middle, and lower thoracic segments were 4.4 ± 0.6, 3.7 ± 1.0, 3.1 ± 0.8, and 2.1 ± 0.9, respectively. The TD scintigraphy demonstrated an uncommon accumulation including that in the right- or bilateral-sided mediastinum or venous angle in 6 (17%) of the 35 patients. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of 3D TD scintigraphy for the detection of anatomical anomalies of TD were 0.75, 0.90, 0.5, 0.97, and 0.89, respectively. Conclusions Three-dimensional TD scintigraphy by BMIPP is a simple and minimally invasive method for imaging the anatomical configuration of the TD and for detecting any anatomical anomalies, except in the lower thoracic segment.

Esophageal gastrointestinal stromal tumors (GISTs): report of three cases

Esophageal gastrointestinal stromal tumors (GISTs) are very rare. We herein report our experience of three cases of esophageal GISTs. Two women and one man were treated by radical surgery either by thoracoscopic or by thoracotomy and thereafter followed up. Both histopathological and immunohistochemical analyses of tissue specimens showed positive findings for c-kit, which confirmed the diagnosis of GISTs. The malignancy of GISTs remains a clinical problem, and various indicators for the risk for recurrence or metastasis have been reported, such as tumor size, mitotic index, and mutation of the c-kit gene. As the tumor size was markedly large in two cases whereas the other had a high mitotic level, they are thought to have malignant potential. Because all three patients have demonstrated a disease-free status for at least 25 months, surgical therapy seems to be sufficient for such patients. However, further long-term follow-up may be necessary.