Kanji Nishiguchi

Comparative evaluation of surgical stress of laparoscopic and open surgeries for colorectal carcinoma

PURPOSE: To objectively evaluate the benefits of laparoscopic procedures for colorectal carcinoma, a prospective study to measure the stress response to laparoscopic surgery (n=15) compared with open surgery (n=12) was undertaken. In addition, to compare the various parameters relevant to surgical stress, the major surgery group (transthoracic esophagectomy for esophageal carcinoma, n=4; and left upper abdominal evisceration for gastric carcinoma, n=3) was assigned. METHODS: Peripheral blood samples were obtained to measure serum interleukin-6, C-reactive protein, peripheral leukocytes, and lymphocyte counts. Additionally, the level of lymphocyte apoptosis was quantified using flow cytometry. RESULTS: The interleukin-6 and C-reactive protein levels were significantly greater in the open group than in the laparoscopy group one day (P<0.05) and two days (P<0.05) after surgery, respectively. In the laparoscopy group, lymphocyte counts were significantly higher than in the open group two days after surgery. The laparoscopy and open groups did not differ significantly in their lymphocyte apoptotic index. In the major surgery group, the apoptotic index was significantly higher than in either the laparoscopy group or the open group in the early postoperative period. CONCLUSION: Changes in the various parameters pertinent to surgical stress evaluated in this study suggest that laparoscopic surgery for colorectal carcinoma leads to less postoperative stress than conventional open surgery.

Impact of the expression of cyclin-dependent kinase inhibitor p27Kip1 and apoptosis in tumor cells on the overall survival of patients with non–Early stage gastric carcinoma

The expression of p27Kip1 and apoptosis have been implicated in tumor aggressiveness and proved to be prognostic predictors for several human malignancies. In this study, the authors sought to investigate the expression of p27Kip1 and apoptosis and their potential significance in determining the prognosis of patients with non–early stage gastric carcinoma.

Clinical study to identify specific characteristics of cancer newly developed in the remnant stomach.

Abstract.Abstract.Background: Cancer newly developed in the remnant stomach (CRS) after partial gastrectomy is worthy of attention not only because it is a typical model of carcinogenesis but also from the aspect of cancer diagnosis.Methods: We treated 47 patients with CRS in the 20 years from 1979 to 1998. Clinicopathological variables, as well as long-term survival results after the second surgery, were reviewed to clarify whether there were any differences in the characteristics of this disease entity compared with the usual primary gastric cancer.Results: The mean time interval between the initial surgery and surgery for CRS was 25.8 years for patients with CRS with previous benign gastric lesions, and 10.6 years for those with previous gastric cancer. CRS was frequently detected at an early stage in the patients with previous cancer, and in the patients who had undergone reconstruction by the Billroth I method (regardless of the primary nature of the disease). Cancers with a differentiated histology developed more frequently in the patients who had undergone the initial surgery for cancer disease. Long-term survival results after the second surgery clearly demonstrated that surgical treatment for CRS was as effective as that for primary cancer in the upper stomach (PUC). In addition, it was confirmed that new lymphatic drainage into the lower mediastinum or the jejunal mesentery had developed after the initial gastric surgery.Conclusion: The findings suggested that patients with CRS and those with PUC should be treated similarly, although the findings of a high incidence of lymph node metastasis to the lower mediastinum and/or to the jejunal mesentery in the CRS patients should be taken into consideration.

Efficacy of intraperitoneal and intravenous chemotherapy and left upper abdominal evisceration for advanced gastric cancer

Background. The study was carried out to evaluate the efficacy of intraperitoneal (IP) and intravenous (IV) chemotherapy, as well as left upper abdominal evisceration (LUAE), for patients with advanced gastric cancer.Methods. We carried out a retrospective study of 348 patients who underwent gastrectomy for advanced gastric carcinoma between 1978 and 1998 at our institution and who had macroscopic type 3 or 4 cancer (Japanese classification) with depth of invasion to the serosal surface, but no liver metastasis or lymph node metastasis around the abdominal aorta. Cumulative survival rates were compared in patients who underwent gastrectomy together with: (1) intraoperative IP chemotherapy alone, (2) postoperative IV chemotherapy alone, (3) both IP and IV, or (4) no chemotherapy. Then patients were stratified according to the presence of peritoneal dissemination (P+) and its absence (P−). In P+ patients, survival was compared between those who received IV chemotherapy and those who did not, and between those who received IP chemotherapy and those who did not. Then, survival was compared between patients with high and low immunosuppressive acidic protein (IAP) levels. Finally, we compared cumulative survival rates in patients (stratified as P+ and P−) who underwent LUAE with cumulative survival rates in those who underwent total gastrectomy combined with resection of the pancreatic body, tail, and spleen (PS).Results. For P− patients, there was no survival advantage with adjuvant IP or IV therapy when compared with surgery alone. For P+ patients, however, there was an improvement in survival when patients received both IP and IV, compared with survival with surgery alone (P < 0.05). In P+ patients aged less than 60 years, there was improvement in survival for those who underwent IP therapy together with surgery (P < 0.05), but not for those who had IV chemotherapy after surgery. When LUAE was examined, there was a survival advantage for this procedure when there was no peritoneal dissemination. Four long-term survivors (surviving for more than 5 years) were identified in our study. Three of the 4 patients were aged less than 60 years, and all 4 had macroscopic type 4 gastric cancers.Conclusion. Although the prognosis for patients with invasive type gastric cancer remains poor, there have been a few long-term survivors, in whom this survival was associated with aggressive combination therapy, including surgery, IP, and IV therapy. P+ patients aged less than 60 years and patients with type 4 gastric cancer may stand to benefit most from such therapy. For P− patients, the role of adjuvant IP or IV therapy continues to be ambiguous, although LUAE in this population may be superior to PS.

Expression of transforming growth factor β (TGF-β) may contribute, in part, to the variations in histogenesis and the prevalence of peritoneal dissemination in human gastric carcinoma

Background. Alterations in the activity of transforming growth factor β (TGF-β) in humans have been implicated in fibrosis, immunosuppression, development of cancer, and other disorders. Scirrhous gastric carcinoma is characterized by cancer cells that infiltrate rapidly in the stroma with extensive growth of fibroblasts and fibrous tissue. Hence, the majority of studies examining the role of TGF-β in gastric carcinoma have focused on scirrhous carcinoma. Methods. We undertook a retrospective immunohistochemical study of gastric carcinoma in order to characterize TGF-β expression in malignant gastric lesions and to determine whether TGF-β expression was related to disease progression. Results. TGF-β expression in scirrhous gastric carcinomas was significantly higher than that in nonscirrhous gastric carcinomas. In patients with advanced gastric carcinoma with surgically curative resection, TGF-β expression was significantly higher in those patients who developed peritoneal recurrence after surgery than in those who did not develop such recurrence. Patients with TGF-β expression-positive tumors had significantly poorer survival than did those with TGF-β expression-negative tumors (P = 0.017). In addition, multivariate Cox proportional hazard model analysis showed that TGF-β immunohistochemical status was an independent prognostic factor (P = 0.0031). Conclusion. These data suggest that TGF-β may contribute, in part, to the variations in histogenesis and to the prevalence of peritoneal dissemination in gastric carcinoma.

Laparoscopic approach for early gastric cancer within a paraesophageal hiatal hernia

We present a case of early gastric cancer located in gastric volvulus associated with paraesophageal hiatal hernia. Two lesions of EGC were diagnosed in the distal third of the stomach, most of which had herniated into the left chest through a large hiatal defect in an organoaxial fashion. Routinely, laparoscopic-assisted distal gastrectomy (LADG) is our preferred approach for EGC, and the presence of hiatal hernia in this case did not alter our approach. Laparoscopic repair of hiatal hernia was performed successfully followed by LADG. A review of the literature supports a minimally invasive approach for both procedures and shows it to be safe, effective, and technically feasible. Further, LADG is shown to be oncologically adequate in terms of tumor margins and lymph node dissection, but its relevance to long-term disease-free survival still needs to be studied in well-designed prospective trials.

USEFULNESS OF MULTI DETECTOR ROW COMPUTED TOMOGRAPHY FOR DETECTION OF FLAT AND DEPRESSED COLORECTAL CANCER

Background:  Recently, the clinical usefulness of colorectal cancer screening by CT colonography has been reported in Europe and the USA. However, in Japan, the diagnosis of flat or depressed colorectal cancer lesions has been emphasized, and the question of whether CT colonography facilitates visualization of these lesions remains to be answered. In the present study, we compared the visualization of flat and depressed colorectal cancer lesions by CT colonography with that of protruding lesions.

Clinical application of 3D-CT angiography for laparoscopic colorectal surgery

The purpose of the study was to examine the role of three dimensional helical CT angiography (3D-CTA) as an adjunct to laparoscopic surgery for colonic carcinomas. For the resection of sigmoid and upper rectal carcinomas under laparoscopy, we routinely perform lymph node dissection around root of IMA with preserving the left colic artery. In addition, for right sided colon carcinomas, we perform lymph node dissection exposing so called the surgical trunk (superior mesenteric vein). For either of these procedures performing safely, it is important to know the precise individual vascular anatomy bearing their variations.

Clinical Characteristics and Immunohistochemical Examination of Gastric Adenosquamous Carcinoma. Expression of Proliferating Cell Nuclear Antigen(PCNA), Apoptotic Cell, p53, CD44 and Intratumoral Microvessel Density(CD34).

胃腺扁平上皮癌 (以下, 本症) の特徴を検索する目的で, 本症を対象として一般型進行胃癌症例 (以下, 一般型) と比較検討した. まず両者を臨床的に比較し, PCNA, Apoptotic cell, p53, CD44, CD34の発現状態を免疫組織化学的に検討した. 臨床的に本症では肝転移率が高く, Stageの高い症例の多いことが特徴であり, その予後は一般型に比べて有意に不良であった. 本症のPCNA陽性細胞率は一般型に比べて有意に高値であり, Apoptotic Indexは一般型より有意に低率であった. p53, CD44発現陽性率は本症ではいずれも一般型に比べて有意に高率であり, 発現陽性例では両癌成分ともに同等に発現していた. さらに, 腫瘍内血管密度の検索では, 本症は一般型に比べて有意に高値であった. 今回の検討から, 本症は増殖活性が高く, p53などの遺伝子異常が蓄積され, アポトーシス活性が低く, 進展過程で豊富な新生血管が生じて癌細胞が転移しやすい状況を形成している可能性が示唆された.

A Case of Peutz-Jeghers Syndrome Associated with Advanced Jejunal Cancer.

我々は進行空腸癌を合併したPeutz-Jeghers症候群 (以下, P-J症) の1例を経験したので報告する. 症例は43歳, 男性のP-J症患者である. 腸閉塞症にて近医より当院を紹介された. 消化管精査の結果, 胃, 小腸および大腸に多発性のポリープを認め, 腸閉塞症状が反復するため外科的治療を行った. 開腹の結果, 腹膜播種を伴う全周性の空腸癌を認め, 組織学的診断は粘液癌であった. 本例は高度進行癌であったため, どのような経路を経て癌が発生したか推察できなかった. P-J症のポリープの癌化を示唆する報告が増えてきた現在, その癌化の機序は解明されるべき重要な課題であると考えられ, P-J症の診断確定時より癌の合併も念頭においた厳重な経過観察を行う必要があると思われた.