Kiyonori Kanemitsu

Alternative lengthening of telomeres frequently occurs in mismatch repair system-deficient gastric carcinoma

Maintenance of telomeric ends by the telomerase ribonucleoprotein complex or the telomerase‐independent alternative lengthening of telomeres is necessary for the immortalization of human cells. The significance of alternative lengthening of telomeres has been suggested in DNA mismatch repair system‐deficient cells; however, much remains unknown in human malignancies. In this study, we investigated the telomere maintenance mechanism in gastric carcinoma. In formalin‐fixed and paraffin‐embedded sections of the high frequency of microsatellite instability (MSI‐H) and non‐MSI‐H gastric carcinomas, there was no difference in telomere length monitored by telomere intensity ratio using telomere‐fluorescent in situ hybridization. Immunoreactivity of hTERT, the catalytic subunit of telomerase, was detected in 48% of MSI‐H gastric carcinomas. The frequency was significantly lower than that in non‐MSI‐H gastric carcinomas (86%, P = 0.02). Conversely, the number of the alternative lengthening of telomeres‐associated promyelocytic leukemia bodies (APBs) detected by combined promyelocytic leukemia immunofluorescence and telomere‐fluorescent in situ hybridization was statistically higher (57%) in the MSI‐H gastric carcinomas compared to that in non‐MSI‐H gastric carcinomas (19%, P = 0.026). The cases with hTERT(+)APBs(–) were more frequent in non‐MSI‐H gastric carcinomas (76%) than in MSI‐H gastric carcinomas (24%), and the cases with hTERT(–)APBs(+) were more frequent in MSI‐H gastric carcinomas (33%) than in non‐MSI‐H gastric carcinomas (10%). These results suggest that alternative lengthening of telomeres‐mediated telomere maintenance plays an important role for microsatellite instability‐mediated stomach carcinogenesis, as well as the telomerase ribonucleoprotein complex, although the incidence of MSI‐H is low. Defects of the mismatch repair system may lead to homeologous recombination of telomeric ends for the telomerase‐independent telomere maintenance in gastric carcinomas. (Cancer Sci 2009; 100: 413–418)

Family history of cancer in Japanese gastric cancer patients

The aim of this study was to evaluate the family history of cancer in Japanese gastric cancer patients and to investigate the clinicopathological features of gastric cancer patients with and without a family history of cancer. Four hundred and forty gastric cancer patients were enrolled in this study. The family history (first- and second-degree relatives) was investigated. The 440 patients were divided into three groups: (1) patients with a family history of gastric cancer; (2) patients with a family history of other cancers; and (3) patients without a family history of cancer. Two hundred and four patients (46.4%) reported a family history of cancer. Gastric cancer was the most frequent, with 98 patients having a total of 123 reports of gastric cancer in the family; colorectal cancer was the second most frequent and lung cancer was the third most frequent. The average ages of the group with a family history of gastric cancer and the group with a family history of other cancers were significantly lower than that of the patients without a family history of cancer. Other clinicopathological factors examined showed no significant difference between the groups. Japanese gastric cancer showed aggregation within second-degree relatives. The average age of the patients in the group with a family history of gastric cancer was the only significant factor that differed between gastric cancer patients with and without a family history of cancer.

Experimental evaluation of the mechanical strength of stapling techniques.

BackgroundThe single stapling technique (SST) and the double stapling technique (DST) are common anastomoses for rectal cancer. Although many mechanical devices have been developed, the best choice remains unclear. In this study we examined the strength of anastomoses by determining their bursting pressures using an animal model.MethodsThe intestines of pigs were used. In experiment 1, we compared the bursting pressures for Endo GIA™ 60 blue, Endo GIA™ 60 green, and GIA™ 60 blue. In experiment 2, the bursting pressures of a buttressed cutting site and a nonbuttressed cutting site were measured. In experiment 3, the SST, DST, and DST with buttress using PCEEA™ were performed and the bursting pressures and points of these anastomoses were examined.ResultsThe bursting pressure of Endo GIA 60 blue (80.3 ± 10.5 mmHg) was significantly higher than that of Endo GIA 60 green (37.3 ± 4.2 mmHg) and GIA 60 blue (31.7 ± 5.8 mmHg) (p < 0.01). When a cut end was buttressed, the bursting pressure (149.6 ± 37.6 mmHg) was significantly higher than that of the nonbuttressed end (75.3 ± 25.1 mmHg) (p < 0.01). The bursting pressure among SST, DST, and DST with buttress was not significantly different. Only one bursting point was the crossing point of the PCEEA and Endo GIA and the bursting pressure of this point was much lower than that of the others.ConclusionEndo GIA was most suitable for DST. The SST, DST, and DST with buttress had almost the same strength. The crossing point of PCEEA and Endo GIA may be a dangerous point for DST.

Prone position in thoracoscopic esophagectomy improves postoperative oxygenation and reduces pulmonary complications.

BackgroundWhile thoracoscopic esophagectomy is a widely performed surgical procedure, only few studies regarding the influence of body position on changes in circulation and breathing, after the surgery, have been reported. This study aimed at evaluating the effect of body position, during surgery, on the postoperative breathing functions of the chest.MethodsA total of 266 patients who underwent right-sided transthoracic esophagectomy for esophageal cancer from 2004 to 2012 were included in this study. Fifty-four of them underwent open thoracotomies in the left lateral decubitus position (Group O), 108 underwent thoracoscopic esophagectomy in the left lateral decubitus position (Group L) and 104 patients were treated by thoracoscopic esophagectomy in the prone position (Group P). Two patients in Group P, who presented with intra-operative bleeding and underwent thoracotomy, were subsequently excluded from the pulmonary function analysis.ResultsTwo patients in Group P had to be changed from the prone position to the lateral decubitus position and underwent thoracotomy in order to control intra-operative bleeding. Despite the significantly longer chest operation period in Group P, total blood loss was significantly lower in this group when compared to Groups O and L. Furthermore, patients in Group P presented with significantly lower water balance during the perioperative period and markedly higher SpO2/FiO2 ratio after the surgery. The incidence of respiratory complications was significantly higher in Group O when compared to the other two groups; however, no significant differences were observed between the Groups L and P.ConclusionThe findings of this study demonstrate that thoracoscopic esophagectomy in the prone position improves postoperative oxygenation and is therefore a potentially superior surgical approach.

Appendicitis with psoas abscess successfully treated by laparoscopic surgery.

Although acute appendicitis is a common disease, retroperitoneal abscesses are rarely observed. Here, we report a case consisting of a psoas abscess and cutaneous fistula caused by appendicitis. The patient was a 56-year-old male who was introduced to our institution due to an intractable right psoas abscess. Imaging tests had been performed over the previous 3 years; however, clinicians could not find the origin of the abscess and failed to resolve the problem. A successful operation was performed via a laparoscopic approach, and 17 mo have passed without recurrence. The advantage of laparoscopic surgery is well understood in cases of appendicitis with abscesses. However, the indication for laparoscopic approach is not clear for retroperitoneal abscesses. From our experience, we can conclude that appendicitis with retroperitoneal abscesses can be managed and treated using a laparoscopic approach.

Treating patients with advanced rectal cancer and lateral pelvic lymph nodes with preoperative chemoradiotherapy based on pretreatment imaging

Preoperative chemoradiotherapy (CRT) and lateral pelvic lymph node (LPLN) dissection (LPLD) based on pretreatment imaging are performed to improve oncological outcomes at our institution. However, the advantage of LPLD following preoperative CRT in advanced rectal cancer remains unclear. The objective of the present study was to assess the validity of this approach. Thirty-two patients with advanced rectal cancer were included in the study. All patients were treated with preoperative CRT and curative operation. Of these, 16 patients who were treated between August 2005 and June 2008 underwent LPLD on both sides (LPLD group). Sixteen patients who were treated between July 2008 and January 2013 underwent LPLD only on the side with suspected LPLN metastasis determined by pretreatment imaging; in cases without LPLN metastasis, only total mesorectal excision was performed (limited-LPLD group). The overall survival and relapse-free survival between the LPLD and the limited-LPLD groups were compared. Preoperative CRT was able to lower clinical lymph node status in 50% of the cases. In addition, pathological lymph node status did not exceed the pretreatment clinical lymph node status stage in the LPLD group. There were no differences in the overall survival and relapse-free survival between the two groups (P=0.729 and P=0.874, respectively). We conclude that multi-imaging studies have a very low risk of overlooking pathologically positive LPLN metastases. Therefore, limited LPLD is a feasible strategy for patients with advanced rectal cancer and suspicious LPLN metastases based on pretreatment imaging.

Simple and Easy Technique for the Placement of Seprafilm During Laparoscopic Surgery

Laparoscopic surgery is a minimally invasive surgery, and the incidence of postoperative small bowel obstruction (SBO) is not high. However, SBO is a disease that detracts from the benefits of laparoscopic surgery due to the need for additional therapies or prolongation of hospital stay. Seprafilm is effective in reducing adhesions and preventing the occurrence of SBO. However, it is very difficult to place the Seprafilm during laparoscopic surgery compared to open surgery. Herein, we report a simple and easy method. The Seprafilm including the holder paper is divided into six pieces; each piece is wound around the end of the forceps and the reduction sleeve is slid over it. The forceps with the reduction sleeve is inserted through a 12-mm trocar and moved closer to the target place. Then, the reduction sleeve is slid down the forceps to expose the Seprafilm. This method does not require any special preparation or training. Based on our experience, this method can easily overcome the problems that the Seprafilm is vulnerable to tear and is difficult to spread out in the abdominal cavity.

Validity of Laparoscopic Gastrectomy in the Elderly

Objectives: This study aimed to investigate the validity of laparoscopic gastric cancer surgery in elderly patients. Methods: A total of 202 patients who underwent laparoscopic gastrectomy for gastric cancer between January 2007 and December 2016 were divided into an elderly group (age ≥75 years, n = 36) and a control group (age < 75 years, n = 166). The patients’ clinicopathological data were reviewed. Results: The overall morbidity rate was relatively higher in the elderly group (16.7 vs. 11.4%, p = 0.389), whereas the incidence of serious complications ≥grade III according to the Clavien-Dindo classification did not increase significantly in the elderly group (8.3 vs. 7.8%, p = 0.920). Univariate and multivariate analyses revealed that age ≥75 years was not a significant predictive factor of postoperative morbidity (p = 0.568). There was no significant difference in the 5-year overall survival rate of patients with pathological stage I gastric cancer between the groups (97.1 vs. 96.1%, p = 0.704; hazard ratio, 0.669; 95% confidence interval, 0.036–3.692). Conclusions: Laparoscopic gastrectomy has an acceptable morbidity rate in elderly patients, and the long-term outcome of patients with stage I gastric cancer was similar to that of the control group.

Laparoscopic ileocecal resection can be applied for appendiceal cancer with an ileal fistula: A case report

Highlights • We experienced a case of appendiceal cancer invading the ileum with a fistula.• This is the first case report of appendiceal cancer with an ileal fistula that successfully treated with laparoscopic resection.• Laparoscopic resection can be a feasible, safe and curative procedure in selected cases of appendiceal cancer with a fistula.• Laparoscopic ileocecal resection can be applied for appendiceal cancers with a fistula by experienced surgeons with careful consideration.

Impact of Gastric Cancer Surgery in Elderly Patients

Objectives: This study aimed to investigate the validity of gastric cancer surgery in elderly patients. Methods: A total of 544 patients who underwent elective gastrectomy for gastric cancer were divided into an elderly group (age ≥75 years, n = 171) and a control group (age <75 years, n = 373). The clinicopathological data of the patients were reviewed. Results: The overall morbidity rate (26.3 vs. 16.1%, p = 0.005) and the incidence rate of anastomotic leakage (6.4 vs. 1.6%, p = 0.003) were significantly higher in the elderly group. The proportion of patients who had severe complications (≥grade IIIa) was relatively higher in the elderly group (10.5 vs. 5.7%); however, the difference was not significant (p = 0.074). A stage-matched survival analysis revealed no significant differences between the groups (stage I: p = 0.978; stage II: p = 0.964; stage III: p = 0.199). For the pathological stages II and III, the overall survival of the patients in the elderly group who received adjuvant chemotherapy for >3 months was significantly better than that of the patients who received it for ≤3 months or did not receive it (p = 0.023). Conclusions: An aggressive treatment strategy should be adopted in selected elderly patients with gastric cancer.