Katsunari Takifuji

Surgical management of small gastrointestinal stromal tumors of the stomach.

Small gastrointestinal stromal tumors (GISTs) (<3 cm) occasionally are found in the stomach during endoscopy. There is no consensus about the surgical management of these small tumors, although this clinical issue is crucial because some of the tumors show unexpected malignant behavior. In this study, we evaluated the clinical management of patients with gastric GISTs who underwent surgical resection. Altogether, 31 patients with gastric GISTs were examined retrospectively. Surgical resection was fundamentally indicated for the patients with gastric GISTs suspected to be malignant by endoscopy or endoscopic ultrasonography (EUS). The malignant grade of the GISTs was evaluated by the mitotic rate, tumor size, and MIB-1 index. EUS was useful for differentiating benign from malignant GISTs; but by limiting the study to patients with small tumors (<3 cm), the diagnostic value of EUS was not satisfactory for defining the surgical indication. Tumors that were <50 mm were successfully treated by laparoscopic surgery. Of the 31 patients, 4 had a relapse of the disease, and 1 of those 4 patients had a small tumor (30 mm). All of the recurrences were classified in the high risk category. Surgery is indicated for gastric GISTs that are ≥20 mm or are suspected to be malignant based on EUS findings. Laparoscopic resection is feasible and is recommended as the treatment of choice for patients with tumors < 50 mm. Risk assessment can be most useful for predicting recurrence.

Effectiveness of the clinical pathway to decrease length of stay and cost for laparoscopic surgery

AbstractsBackground: Although clinical pathways have become popular strategies to improve the quality of medication in the field of laparoscopic surgeries, their economical effectiveness is not well defined. The aim of this study was to investigate the effect of clinical pathways for laparoscopic surgeries on cost and length of hospital stay. Methods: From January 2000 to June 2001, clinical pathways were introduced for laparoscopic surgeries, such as laparoscopic cholecystectomy (Lap. C, n = 210), laparoscopically assisted distal gastrectomy with Billroth-I reconstruction (Lap. B-I, n=33), and laparoscopically assisted colectomy (Lap. colon, n=34). We compared total lengths of hospital stay and the economical efficiency before and after pathway implementation at Wakayama Medical University Hospital. Results: The length of hospital stay in Lap. C was shortened from 7.8±2.6 (mean±SD) days to 6.9±2.0 days (p = 0.03) and the total costs during hospitalization decreased from ¥509,320±58,800 to ¥489,130±43,860 (p=0.009), resulting in less burden for patients. At the same time, the daily costs were increased from ¥66,230±8920 to ¥70,840±6820 (p=0.0001), indicating that more efficient medical care was being given to patients. Similar results were obtained in Lap. B-I and Lap. colon groups. Conclusions: In our study, the implementation of clinical pathways in the field of laparoscopic surgeries produced significant decreases in length of total hospital stay and cost while maintaining the quality of patient outcomes.

Re‐expression of CEACAM1 long cytoplasmic domain isoform is associated with invasion and migration of colorectal cancer

Carcinoembryonic antigen‐related cell adhesion molecule 1 (CEACAM1) is known to be downregulated at the transcriptional level in adenoma and carcinoma. Recent reports have shown that CEACAM1 is overexpressed at protein level in colorectal cancer and correlated with clinical stage. The reason why colorectal cancer cells re‐expressed CEACAM1 remains unclear. The aim of our study was to clarify the implication of CEACAM1 re‐expression in colorectal cancer. Immunohistochemical analyses were conducted with CEACAM1 long (CEACAM1‐L) or short (CEACAM1‐S) cytoplasmic domain‐specific antibodies on clinical samples from 164 patients with colorectal cancer. The risk factors for metastasis and survival were calculated for clinical implication of CEACAM1 re‐expression. Invasion chamber and wound healing assays were performed for the effect of CEACAM1 expression on invasion and migration of colorectal cancer cells. CEACAM1‐L and CEACAM1‐S stained with greater intensity at the invasion front than at the luminal surface of tumors. Differences between the long and short cytoplasmic isoform expression levels were observed at the invasion front. Multivariate analysis showed that CEACAM1‐L dominance was an independent risk factor for lymph node metastasis, hematogenous metastasis and short survival. The Kaplan–Meier evaluation demonstrated that CEACAM1‐L dominance was associated with shorter survival time (p < 0.0001). In the invasion chamber and wound healing assays, CEACAM1‐L promoted invasion and migration. Re‐expression of CEACAM1 is observed at the invasion front of colorectal cancer. CEACAM1‐L dominance is associated with metastasis and shorter survival of the patients with colorectal cancer. CEACAM1‐L dominance is important for colorectal cancer cells invasion and migration.

Laparoscopic splenectomy is a safe and effective procedure for patients with splenomegaly due to portal hypertension

BACKGROUND/PURPOSE This study was conducted retrospectively to examine whether laparoscopic splenectomy is an effective procedure for patients with splenomegaly due to portal hypertension in comparison to patients with a normal-sized spleen. METHODS From September 1994 to May 2005, we performed laparoscopic splenectomy in 50 patients at Wakayama Medical University Hospital, Japan. Of these, 17 patients with splenomegaly due to portal hypertension and 17 patients with idiopathic thrombocytopenic purpura (ITP) with normal-size spleen were enrolled in this study, in which we compared the surgical outcome between patients with splenomegaly due to portal hypertension and those without splenomegaly (ITP group). RESULTS The mean operative time (splenomegaly due to portal hypertension vs ITP; 171 vs 165 min; P = 0.7433) and estimated blood loss (248 vs 258 ml; P = 0.5396) were similar in the two groups. There were two patients with complications (11.8%) in the patients with splenomegaly due to portal hypertension and five patients with complications (29.4%) in those with ITP. All patients with splenomegaly due to portal hypertension showed appropriate increases in the platelet count following surgery. No perioperative mortality occurred. CONCLUSIONS We concluded that laparoscopic splenectomy was an effective procedure for splenomegaly due to portal hypertension, with findings being similar to those observed in patients with a normal-sized spleen (such as patients with ITP).

Clinicopathological characteristics of remnant gastric cancer after a distal gastrectomy.

IntroductionThe survival rate of patients with remnant gastric cancer (RGC) is unfavorable in comparison to that of cancer in the nonresected stomach. However, when RGC is curatively resected, no significant differences have been reported between both groups in regard to survival. The aim of this study is to analyze the clinicopathological factors influencing a curative resection of RGC.MethodsThirty-eight consecutive patients with RGC from January 1, 1994 through March 31, 2009 were enrolled in this retrospective study.ResultsTheir primary diseases were gastric cancers (21; 55.3%) and benign diseases (17; 44.7%). The type of the reconstruction methods of first gastrectomy were Billroth I (28; 73.7%) and Billroth II (10; 26.3%). A total of 31 patients underwent a laparotomy. Twenty patients underwent a curative resection, four patients underwent a palliative resection, and seven underwent a nonresective operation. A total of seven patients underwent an endoscopic resection for early gastric cancer, and all patients received a curative resection. Univariate and multivariate logistic regression analyses were performed to identify the clinicopathological and background factors influencing a curative resection of RGC. A multivariate analysis revealed only an annual follow-up endoscopic examination after the initial gastrectomy to be an independent factor for a curative resection (p = 0.016; odds ratio, 35.3).ConclusionsAn annual follow-up endoscopic examination an after initial gastrectomy may be related to improving the prognosis of patients with RGC.

C-Reactive protein is an independent surgical indication marker for appendicitis: a retrospective study

BackgroundThis study is an attempt to clarify the role of C-reactive protein (CRP) as a surgical indication marker for appendicitis.MethodsOne hundred and fifty patients who underwent appendectomies and had pathologically confirmed appendicitis were reviewed between May 1, 1999 and September 31, 2007. The correlation between preoperative clinical factors and the actual histological severity, and identify surgical indication markers were assessed by univariate and multivariate analyses.ResultsUnivariate analysis showed that only the CRP level significantly differ between the surgical treatment necessary group (gangrenous appendicitis) and the possible non-surgical treatment group (catarrhalis and phlegmonous appendicitis). Multivariate analysis indicated only the CRP level to be a surgical indication marker for acute appendicitis. The receiver-operating characteristic (ROC) curve indicated that the cutoff value of CRP for surgical indication of appendicitis is 4.95 mg/dl.ConclusionOnly the CRP level is consistent with the severity of appendicitis, and considered to be a surgical indication marker for acute appendicitis.

Optimal Dose of Preoperative Enteral Immunonutrition for Patients with Esophageal Cancer

PurposeA preoperative immunonutrition pharmaceutics diet (IMPACT) significantly reduced the incidence of postoperative infectious complications, but the optimal regimen still remains unclear. We evaluated the optimal dose of a preoperative IMPACT for patients with esophageal carcinoma and the incidence of postoperative complications based on the dose of IMPACT.MethodsThis study design was a prospective nonrandomized study. Twenty patients with thoracic esophageal carcinoma who underwent a right transthoracic subtotal esophagectomy were divided into two groups. These patients were administered immunonutrition of 500 ml/day (IMP500) or 1000 ml/day (IMP1000) for 7 days before the operation.ResultsThe incidence of postoperative mortality and morbidity was not different between the IMP500 group and the IMP1000 group. No difference was observed in the perioperative changes in inflammatory, immunological and nutritional variables between the two groups. There were no adverse effects in the IMP500 group, but four patients (40%) had diarrhea and four patients (40%) had appetite loss in the IMP1000 group. In the IMP1000 group, only four patients (40%) could take 1000 ml, but others reduced the quantity of IMPACT because of diarrhea and discomfort.ConclusionThis study suggests that 500 ml of IMPACT is recommended as an optimal dose for patients with esophageal cancer.

Randomized clinical trial of defaecatory function after anterior resection for rectal cancer with high versus low ligation of the inferior mesenteric artery

Defaecatory function is often poor after anterior resection. Denervation of the neorectum following high ligation of the inferior mesenteric artery (IMA) is a possible cause of impaired defaecatory function. The purpose of this randomized clinical trial was to clarify whether the level of ligation of the IMA in patients with rectal cancer affects defaecatory function.

Reconstruction of an infected recurrent ventral hernia after a mesh repair using a pedicled tensor fascia lata flap: Report of two cases

Recently, the use of prosthetic mesh has revolutionized the repair of ventral hernias. However, the occurrence of infection related with the use of this prosthesis remains an important complication, which may result in occurrence of fistula formation of the skin or intestine, sepsis, or reoccurrence of ventral hernia. This report presents two cases where a pedicled musculocutaneous flap using the tensor fascia lata (pedicled TFL flap) was effective as a treatment for an infectious large abdominal hernia, and reviews the previous literature. Two Japanese men aged 61 and 78 years old underwent a ventral hernia repair using Composix Kugel mesh. They both developed a wound infection with methicillin-resistant Staphylococcus aureus. Conservative therapy was not successful and the defect in the abdominal wall of two patients measured 12 × 21 cm and 7 × 10 cm in length, respectively. Reoperations were performed by removing the infectious mesh and then reconstructing the abdominal wall with the bilateral and left-side pedicled TFL flaps, respectively. No recurrence of the ventral hernia has been recognized for 50 months and 7 months after reoperation, respectively. A review of previous studies showed that no patients treated with a pedicled TFL flap experienced a recurrent hernia. Therefore, the pedicled TFL flap was considered to be effective for infectious large abdominal recurrent hernia.

Complications of endoscopic submucosal dissection for gastric noninvasive neoplasia: an analysis of 647 lesions.

Purpose: This study aimed to determine risk factors for postoperative complications of gastric endoscopic submucosal dissection (ESD). Methods: This retrospective study included 647 lesions in 580 consecutive patients who underwent ESD for gastric noninvasive neoplasia from January 1, 2002 through December 31, 2011. Results: The overall perforation rate was 5.1%. Multivariate logistic regression analysis indicated that perforation was significantly associated with tumors in the greater curvature of the stomach (P<0.0001), scars in tumor lesions (P=0.002), long operative time (P=0.007), and tumors in the remnant stomach (P=0.036). The bleeding rate after gastric ESD was 3.9%. Multivariate logistic regression analysis indicated a statistically significant association between postoperative bleeding and oral anticoagulant or antiplatelet drugs (P<0.0001), dialysis (P=0.009), and use of antihypertensive drugs (P=0.015). Conclusion: It is important to perform gastric ESD with particular care in patients with risk factors.