Kenji Wadamori

In vitro and in vivo analysis of human leukocyte binding by the antitumor polysaccharide, lentinan

Lentinan (LNT), a (1-->3)-beta-D-glucan with (1--6)-beta-D-glucopyranoside branches, has marked antitumor effects in syngeneic and autochtonous hosts. Clinically, LNT has proved effective with chemotherapeutic agents in patients with recurrent gastric and colorectal cancer. However, the mechanism that triggers subsequent immunologic reactions remains obscure. We hypothesized that LNT must first bind to the host cells. Accordingly, we analyzed LNT binding to host cells in healthy volunteers after incubating their cells under a variety of conditions as well as intravenously injecting LNT then subjecting them to flow cytometry and immunofluorescent staining using monoclonal antibody (anti-LNT mAb). LNT bound to monocytes and neutrophils, but not to lymphocytes in vitro. The most avid LNT binding was to monocytes. The percentage of LNT-bound monocytes after 60 min incubation at 4 degrees C was greater than that at 37 degrees C. The binding of LNT to monocytes was inhibited slightly by anti-iC3b receptor (anti-CR3) mAb, strongly by anti-C3b receptor (anti-CR1) mAb, and completely by anti-CR1 and anti-CR3 mAb together. The percentages of LNT-binding monocytes in the peripheral blood increased significantly 3 and 4 after 2 mg LNT-injection and returned to low levels 5 h later. However, no increase in LNT-binding neutrophils and lymphocytes was observed. We concluded that binding of LNT to human monocytes may initiate the influence of this compound on the immune system and differ between individuals. Its binding site may be similar to the C3b receptor.

Volume replacement with polyglycolic acid mesh for correcting breast deformity after endoscopic conservative surgery.

From April 2002 to August 2003, 60 patients (41 patients undergoing quadrantectomy and 19 patients undergoing wide excision) with early-stage breast cancer underwent endoscopic breast-conserving surgery and volume replacement with absorbable materials. The average volume of resected tissue was 75 mL (range, 15-145 mL). The absorbable materials consisted of polyglycolic acid mesh (Dexon Mesh DMS#4 10 × 12) folded and wrapped in oxidized regenerated cellulose, which just fit into the dead space. We expected that the polyglycolic acid mesh would help induce granulation and fibrous tissue with reactive tissue fluid and that oxidized regenerated cellulose would prevent adhesion between the skin and the polyglycolic acid mesh (Figure 1). The absorbable materials were gently inserted into the dead space, and the wound was closed in 3 layers. We used 1 sheet of polyglycolic acid mesh and 1 sheet of oxidized regenerated cellulose if the volume loss was 70 mL. The cosmetic outcome was evaluated with a 4-point scoring system of breast cosmesis judged by breast surgeons.1 The scores of breast cosmesis were evaluated every 1 or 2 months at a clinic. The average evaluation time was 6.1 months after surgery (range, 2-12 months). A favorable cosmetic outcome (excellent) was obtained in 83% of patients (77% of patients undergoing quadrantectomy and 91% of patients undergoing wide excision). Dynamic contrast-enhanced magnetic resonance mammography and ultrasonography were performed routinely 3 months after the operation. The images showed that the dead space was lined by granulated scar tissue and filled with fluid. Deformity was almost completely prevented, and the symmetric images helped us to detect local recurrence. In 1 patient, multiple cancers were detected by pathologic examination after conservative breast surgery. Total mastectomy was performed 1 month after the previous operation, and the resected tissue in which polyglycolic acid mesh had been inserted was examined pathologically. Pathologic examination showed that the peripheral part of the dead space was encapsulated by granulation and fibrous tissue, and the mesh was decomposed and phagocytosed by macrophages. Complications of the film-screen mammography (FSM) method were inflammation and overproduction of fluid induced by the polyglycolic acid mesh. These findings were observed in 3 cases that had been diagnosed by open biopsy before surgery. We believe that the open biopsy procedure induced inflammation and overproduction of fluid in these patients. We now regard a history of open biopsy to be a contraindication for the FSM method. It is likely that polyglycolic acid mesh helps to promote granulation and to fill the reactive fluid space in the encapsulating scar. The FSM method is a simple and useful procedure for preventing breast deformity after conservative surgery.

Interleukin-6 and granulocytic elastase levels following laparoscopic cholecystectomy

Interleukin-6 (IL-6) levels have been shown to correlate well with the magnitude of surgical stress. Serum IL-6 and plasma granulocytic elastase levels, 24 h after surgery, were determined in 12 patients who underwent open major surgery [MS group; esophageal carcinoma (n=5), gastric carcinoma (n=3), colorectal carcinoma (n=4) 5 patients who had open cholecystectomy [OC group] and 17 patients who had laparoscopic cholecystectomy [LC group]. IL-6 levels correlated significantly with the duration of surgery (r=0.685,P < 0.01) and with intraoperative blood loss (r=0.583,P < 0.02). However, there was no significant correlation between granulocytic elastase and the duration of surgery or blood loss. Plasma IL-6 levels in the LC group (21±3 pg/ml) were significantly lower than those in the OC group (47±5 pg/ml) and the MS group (186±36pg/ml) (P<0.05;P<0.01). However, there was no significant difference in granulocytic elastase levels between the LC group (318±8μg/l), the OC group (360±130 gmg/ml), and the MS group (701±344 μg/l). Increased IL-6 levels correlated well with increased duration of surgery. The lower IL-6 levels following laparoscopic cholecystectomy may therefore be indicative of lower surgical stress associated with laparoscopic cholecystectomy.

The surgical management of synchronous hepatocellular carcinoma and thoracic esophageal carcinoma

A 73-year-old man was hospitalized with pathologically documented hepatocellular carcinoma and cirrhosis, and a 5.0-cm tumor located in the left lobe was resected by a left lateral segmentectomy. At the same time, metastatic squamous cell carcinoma was identified by frozen section in a perigastric lymph node in the lesser omentum. Intraoperative endoscopy revealed a 1.0-cm erosive lesion in the thoracic esophagus that was subsequently found to be primary squamous cell carcinoma. Seven weeks later, a transthoracic subtotal esophagectomy with substernal, cervical esophagogastrostomy was performed. Twenty-two months after these resections there has been no recurrence of either the hepatocellular or esophageal carcinomas.

Pylorus-Preserving pancreatoduodenectomy in Japan: History and present status

We review several Japanese reports regarding pylorus-preserving pancreatoduodenectomy (PPPD), including our previous survey of a totll of 313 patients who had undergone PPPD as of September, 1989 at 82 major medical facilities. PPPD in Japan was initially performed in 1981 in a patient with leiomyosarcoma of the pancreas. Because of extensive growth of the tumor, right hemicolectomy was also performed and the alimentary tract was reconstructed in the new Billroth I procedure. Many reports have since indicated that PPPD yields favorable results. The patient characteristics ranged widely, from benign diseases to malignancies, including cancer of the pancreas. The use ofPPPD is how increasing both in Japan and in the United States and Europe. The operative techniques, reconstruction methods, morbidity, mortality, survival, and pathophysiology of PPPD in Japan are reviewed in comparison with these factors in the Whipple resection.

A Case Report of Superior Mesenteric Artery Syndrome after abdominoperineal Excision of Rectal Cancer.

上腸間膜動脈症候群 (以下, SMASと略記) は急激な体重減少を契機として発症することが多く, 原則的には保存的治療が奏効する. われわれは, 直腸癌の腹会陰式直腸切断術後にSMASを発症し, 保存的治療が無効で手術を施行した症例を経験した. 術後に小腸が小骨盤腔に落ち込み強固に癒着して腸間膜根の過緊張をきたし, 上腸間膜動脈が十二指腸水平脚を圧迫したことが原因であった. これに対して十二指腸授動術を行い, いったんは軽快したがSMASは再発した. 再手術では十二指腸空腸側々吻合術を施行した. 術後8年経過した現在に至るまで腸閉塞は起こさず, 良好に経過している.SMASの手術適応は諸家によりさまざまであるが, 上部消化管造影と超音波検査とをあわせて腸間膜根部の可動性を適切に評価することが治療方針を決定する上で重要である. 手術術式は, 十二指腸空腸側々吻合術が, 手技的にも簡単で吻合口も十分にとれ治療効果も確実な方法として推奨される