Katsunori Nishikawa

Intraoperative thermal imaging in esophageal replacement: its use in the assessment of gastric tube viability.

We examined the use of intraoperative thermal imaging to assess the gastric vascularization and gastric tube viability during esophagectomy. The surface temperatures of the intact stomach, devascularized stomach, and gastric tube were measured in 13 patients from the proximal end to the pylorus longitudinally along the greater curvature or along the entire gastric tube during esophagectomy. Thermal images clearly demonstrated a surface temperature decline in the proximal region of the gastric tube. The mean decline rate in the surface temperature in the proximal region of the gastric tube in comparison to the intact stomach was 17.7% (P < 0.001). One patient who developed gastric tube necrosis exhibited a prominent drop in the surface temperature in the proximal region of 20.6% in comparison to that in the distal region, compared to that of 12.5% in other patients. Intraoperative thermal imaging is a noninvasive and reliable technique for the assessment of the gastric tube viability.

How Can We Control Intraoperative Bacterial Contamination and Surgical-Site Infection During an Anterior Resection or Hartmann’s/Miles’ Operation?

PurposeIntraoperative bacterial contamination (IBC) is a major cause of surgical-site infection (SSI). Therefore, we investigated whether the ingenuity of surgical procedures could reduce the incidence of IBC/SSI.MethodsSixty patients who were surgically treated for recto-sigmoid cancer were investigated. Among these patients, the colon was transected during the early perioperative period (ET) in 29 patients and during the late period (LT) in 31 patients. Three samples for IBC were obtained from the irrigation fluid before abdominal closure (LAVAGE), the remaining cut sutures after peritoneal closure (SUTURE), and a subcutaneous swab of the wound (SUBCUT).ResultsThe overall SSI and IBC rates were 25% and 55.2%, respectively. Patients who developed SSI had an extremely high IBC rate (85%), and IBC patients also had a high SSI rate (68%). IBC was highest in the LAVAGE (26%) followed by the SUBCUT (26%), and the SUTURE (12%). The incidence of IBC in the LT was significantly lower than that in the ET (19% vs. 55%, p < 0.01), although the incidence of SSI was similar in both IBC groups.ConclusionShortening the exposure of the colonic mucosa decreased the incidence of IBC/SSI; thus, careful operations to minimize IBC are recommended.

Significant response to ramucirumab monotherapy in chemotherapy‑resistant recurrent alpha‑fetoprotein‑producing gastric cancer: A case report

Alpha-fetoprotein (AFP)-producing gastric cancer (AFPGC) is a relatively rare type of gastric cancer characterized by a high incidence of liver and lymph node metastases, and a poor prognosis. Few advanced AFPGC cases treated successfully with conventional chemotherapy have been reported thus far. Although the development of molecular-targeted therapy has improved the prognosis of various types of cancer, there are currently no tailored therapies for AFPGC. In the present report, the case of a chemotherapy-resistant recurrent AFPGC patient who exhibited a significant response to ramucirumab monotherapy is presented. Following six doses of ramucirumab, a metastatic lymph node displayed central necrosis, and the patients serum AFP levels decreased from 12,800 to 225 ng/ml. AFPGC is known to have increased vascular endothelial growth factor (VEGF) expression and rich neovascularization. Furthermore, in the present case, tumor cells were positive for VEGF. Ramucirumab is a monoclonal antibody for VEGF receptor-2 and the first anti-angiogenic drug approved for the treatment of advanced gastric cancer. However, the clinical efficacy of ramucirumab in patients with AFPGC has not been reported previously. The present report suggests that AFP production in gastric cancer can be a predictor for the response to anti-angiogenic drugs such as ramucirumab.

Early measurement of urinary N-acetyl-β-glucosaminidase helps predict severe hyponatremia associated with cisplatin-containing chemotherapy

BACKGROUND Although cisplatin is a widely used anticancer drug for treating various types of cancer, its clinical application is limited by severe systemic toxicities, such as nephropathy, hematologic toxicity, and gastrointestinal toxicity. There are no reliable and validated biomarkers to predict adverse events caused by cisplatin. METHODS Sixty-six patients who underwent cisplatin-containing first-line chemotherapy between June 2010 and November 2013 were retrospectively analyzed. Data on urinary N-acetyl-β-glucosaminidase activities measured 24-48 h after cisplatin infusion were retrieved, and adverse events during the first course of chemotherapy were recorded according to the Common Terminology Criteria for Adverse Events version 4.0. RESULTS Patient characteristics were: male/female 60/6, median age 65 (range 36-78) years, esophageal/gastric/other cancer 60/4/2, chemotherapy regimen docetaxel-cisplatin-fluorouracil/fluorouracil-cisplatin/S-1-cisplatin 54/8/4, cisplatin dose (mg/sm) 60/70/80 16/43/7. Grade 3/4 adverse events were leukopenia (40.9%), neutropenia (54.4%), febrile neutropenia (37.9%), hyponatremia (28.8%), and acute kidney injury (37.9%). Patients with 20 units/gram creatinine or higher urinary N-acetyl-β-glucosaminidase developed statistically lower minimum serum sodium concentration (median 126 vs. 134 mEq/L, p = 0.0053). There were no significant correlations between urinary N-acetyl-β-glucosaminidase and the development of other severe adverse events. CONCLUSION Early significant increase in urinary N-acetyl-β-glucosaminidase predicts subsequent development of severe hyponatremia after cisplatin-containing chemotherapy.

Complete response of esophageal small cell carcinoma amrubicin treatment

Small cell carcinoma of the esophagus (SmCCE) is a rare and aggressive disease known to have a poor prognosis. SmCCE patients are generally treated with a chemotherapeutic regimen for small cell lung cancer. Salvage therapy for patients with relapsed or refractory tumors has not yet been established. A 63-year-old man with extensive SmCCE was treated with chemotherapy consisting of cisplatin (CDDP) and irinotecan (CPT-11). After the second course of CPT-11/CDDP, the celiac lymph node increased in size. Amrubicin (AMR) as second-line chemotherapy was started. The patient had a complete response after the fifth course of AMR, resulting in an 8-month progression-free survival after initial administration. This case suggests that, as in small cell lung cancer, AMR is effective for SmCCE.

Video-Assisted Thoracoscopic Surgery for Localized Neurofibroma of the Esophagus: Case Report and Review of the Literature

Esophageal submucosal tumors are less common than other gastrointestinal tract tumors. Leiomyoma is the most common benign esophageal SMT, accounting for more than 70% of these tumors. We report on a case of a 56-year-old woman with a 3-cm diameter midthoracic esophageal submucosal tumor. Magnetic resonance imaging suggested leiomyoma or neurofibroma. Video-assisted thoracoscopic surgery was performed to enucleate the tumor from the esophageal wall by splitting the muscle layers. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. Immunohistochemical staining confirmed the diagnosis of esophageal neurofibroma. Gastrointestinal tract involvement of neurofibromatous lesions is rare and occurs most frequently as a systemic manifestation of von Recklinghausen disease. Cases of localized esophageal neurofibroma with prior or subsequent evidence of generalized neurofibromatosis have rarely been documented. This is a rare case of isolated esophageal neurofibroma without classic systemic manifestations of generalized neurofibromatosis, and it is the first reported case treated by video-assisted thoracoscopic surgery.

The outcomes of 400 laparoscopic Heller-Dor operations (LHD) for esophageal achalasia

METHODS: Mean age was 44.6 (9-83) years, 189 (47%) were women. These patients were divided into 4 groups: very early, early, mid, and late groups. The clinical pathway was introduced from August 2008 (62nd case). Six and 20 patients underwent RPS in both mid and late group, respectively. Their clinical data were collected in a prospectively fashion and retrospectively reviewed. Their characteristics, preoperative clinical conditions, and the therapeutic outcomes of LHD were assessed in terms of gender, age, length of symptoms, morphologic type, the maximum horizontal diameter of the esophagus (Grade I [<3.5 cm], Grade II [ 3.5 cm but <6.0 cm], and Grade III [ 6.0 cm]), operation time, blood loss, perioperative complications, time to start oral intake (TSOI), postoperative hospital stay (POHS), and the incidence of postoperative reflux esophagitis (PORE).

EXPERIMENTAL STUDY ON GALLBLADDER EMPTYING AFTER TOTAL GASTRECTOMY

Using adult mongrel dogs, we experimentally investigated the gallbladder emptying after total gastrectomy from the relation ship between the endogenous cholecystokinin (CCK) secretion kinetics and the blind-loop duodenal motility.Postprandial gallbladder emptying was about 60% by 60 minutes in the totally gastrectomized dogs, the same as in the control dogs, then the volume increased. Serum CCK secretion in the totally gastrectomized dogs rapidly increased until 50 minutes after the meal in accordance with the gallbladder emptying compared with the control dogs. On the other hand, during fasting the gallbladder underwent partial refilling synchronous with phase I in the blind-loop duodenum and emptying throuth phase II into the latter half of phase II, but the volume of the gallbladder was greater than that in the control dogs. Moreover, the cycle of gallbladder partial emptying and refilling was prolonged with prolongation of the phase III appearance cycle. Variation of serum CCK secretion during fasting was not observed.From the above redults, it is suggested that the abnormality of gallbladder emptying after total gastrectomy mainly depends on the change in the endogenous CCK secretion kinetics in the digestive state and, on the other hand, in the interdigestive state it is correlated with the change in the blind-loop duodenal motility pattern.