Kyuzo Fujii

T lymphocyte subsets and Th1/Th2 balance after laparoscopy-assisted distal gastrectomy

Background: Laparoscopic surgery provides for a less invasive procedure than open surgery in patients with gastric cancer, but the immune responses after laparoscopic surgery for early gastric cancer remain unknown. Methods: Peripheral blood mononuclear cells from 20 patients with early gastric cancer who underwent laparoscopy-assisted distal gastrectomy (LADG) or open distal gastrectomy (ODG) were obtained; the cell surface molecules and intracellular cytokines (IFN-gamma and IL-4) were measured by flow cytometry. Results: The populations of T lymphocytes after LADG, including CD3-, 4-, 8-, 57-, and HLA-DR-positive lymphocytes, showed patterns similar to those after ODG. The production of IFN-gamma as Th1 cell function decreased significantly on the third postoperative day after ODG but increased after LADG. The production of IL-4, representing Th2 cell function, increased postoperatively after ODG but not after LADG. Conclusions: When compared with ODG, LADG contributes to the preservation of postsurgical Th1 cell-mediated immune function.

Increased expression of P-cadherin mRNA in the mouse peritoneum after carbon dioxide insufflation

BackgroundAlthough systemic responses to carbon dioxide (CO2) pneumoperitoneum have been studied, there have been few reports of local responses within the peritoneum. We investigated the expression of mRNA for adhesion molecules involved in cell-cell interactions, including ICAM-1, VCAM-1, CD44, E-cadherin, P-cadherin, and N-cadherin, afte the induction of a CO2 pneumoperitoneum in miceMethodsMice were treated with CO2 pneumoperitoneum (4–6 mmHg for 30 min) and then killed after 24 h, 48 h, and 72 h. The peritoneum of the abdominal wall was resected, and total RNA was extracted by the acid guanidinium thiocyanate-phenol-chloroform extraction procedure, cDNA were synthesized by reverse transcription. Expression of the mRNA for each gene was normalized to that of β-actin for semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR).ResultsThe expression of P-cadherin mRNA was significantly increased at 48 h (p=0.007) and returned to the control level by 72 h after CO2 pneumoperitoneum. The expression of CD44 increased gradually, reaching a peak at 48 h and returning to the control value by 72 h after CO2 pneumoperitoneum. Expression of ICAM-1 mRNA was not changed significantly after the application of CO2.ConclusionThe expression of P-cadherin mRNA in the peritoneum can be induced to repair injuries to mesothelial cells caused by CO2 pneumoperitoneum.

Increased peritoneal dissemination after laparotomy versus pneumoperitoneum in a mouse cecal cancer model.

BackgroundThe effect of carbon dioxide (CO2) pneumoperitoneum on the liberation of cancer cells from the primary tumor is not clear. This study investigated the influence of laparotomy versus CO2 pneumoperitoneum on the progression of colon cancer with serosal invasion in a mouse model.MethodsPieces of human colon adenocarcinoma (HT29) tumor were implanted in the cecal wall of 45 BALB/c nude mice. Each mouse underwent one of three procedures: laparotomy, CO2 pneumoperitoneum, or anesthesia (control). Three weeks later, the size and weight of cecal tumors, the number of nodules, and the tumor volume score of peritoneal dissemination were examined. Another 45 mice were treated in the same way. The cecal tumor was resected on days 1, 3, or 5 after treatment. Total RNA was isolated from the resected tumors. The expression of E-cadherin and beta-1 integrin messenger RNA (mRNA) was examined by semiquantitative real-time reverse transcriptase–polymerase chain reaction assay.ResultsSignificantly more nodules of peritoneal dissemination were found in the laparotomy group than in the control group (p < 0.05). The tumor volume score of peritoneal dissemination in the laparotomy group was significantly higher than in the other two groups (p < 0.05). The expression of E-cadherin mRNA at day 5 in the laparotomy group was significantly less than in the other two groups (p < 0.05). There were no differences in beta-1 integrin among three groups.ConclusionsPeritoneal dissemination was more extensive after laparotomy than after CO2 pneumoperitoneum in a mouse model of cecal cancer with serosal invasion. Decreased expression of E-cadherin mRNA in tumors after laparotomy, but not after CO2 pneumoperitoneum, may be associated with the increase in peritoneal dissemination.

Less impaired cell-mediated immune response in the murine peritoneal cavity after CO(2) pneumoperitoneum.

AbstractPurpose. We compared changes in the populations of peritoneal T lymphocytes and natural killer (NK) cells after CO2 pneumoperitoneum and laparotomy to clarify whether pneumoperitoneum affects cell-mediated immune responses in the peritoneal cavity. Methods. We analyzed and compared populations of T lymphocytes and NK cells among peritoneal exudative cells (PECs) collected from 185 female mice subjected to pneumoperitoneum, laparotomy, or anesthesia only. PECs were collected postoperatively, and the populations of T lymphocytes and NK cell subsets were analyzed by flow cytometry. The NK cell cytotoxicity (NKCC) of PECs and splenocytes was measured. Results. The populations of CD3+, CD4+, and CD8+ lymphocytes in the PECs continued to increase up until postoperative day (POD) 7 after laparotomy. The CD4/8 ratio on POD 3 was significantly lower after laparotomy than after pneumoperitoneum. The percentages of NK cells in the pneumoperitoneum group were significantly lower than those in the laparotomy group. On POD 1, the NKCC of splenocytes was less impaired in the pneumoperitoneum group than in the laparotomy group (10.3% vs 5.0%, P ≪ 0.05). Conclusion. Laparoscopic surgery is preferable to open surgery because it results in less impairment of systemic and intraperitoneal cell-mediated immune responses.

Learning curve for laparoscopy‐assisted distal gastrectomy

Background:  Laparoscopy‐assisted distal gastrectomy (LADG) has proved to be useful in the management of early gastric cancer. The aim of the present study was to examine the learning curve for LADG and clarify any technical problems.

Laparoscopic surgery for the diagnosis and treatment of a paracecal hernia repair: Report of a case

Internal hernias are relatively rare viscous protrusions through a defect in the peritoneal cavity. Paracecal hernia is one of the least common types, and only a few cases have been reported to date. We herein present the case of a 43-year-old woman, who was preoperatively diagnosed to have a small bowel obstruction caused by a paracecal hernia resulting from intestinal protrusion and invagination into a paracecal pouch. Laparoscopic surgery was performed for definitive diagnosis and treatment. The surgery achieved a good outcome and the patient experienced an uneventful perioperative course.

Prospective Feasibility Study to Evaluate Neoadjuvant-synchronous S-1 + RT for Locally Advanced Rectal Cancer: A Multicenter Phase II Trial (UMIN ID: 03396)

In Western countries, the standard treatment for locally advanced rectal cancer is preoperative chemoradiotherapy followed by total mesorectal excision. However, in Japan, the treatment results without preoperative chemoradiotherapy are by no means inferior; therefore, extrapolation of the results of preoperative treatment in Western countries to Japan is controversial. We consider that survival may be improved by preoperative chemoradiotherapy with new anticancer agents as they are expected not only to decrease the local recurrence rate but also to prevent distant metastases. We are conducting a multicentre Phase II study to evaluate the safety and efficacy of neoadjuvant chemoradiotherapy using S-1 in patients with locally advanced rectal cancer. The primary endpoint is the rate of complete treatment of neoadjuvant chemoradiotherapy. Secondary endpoints are the response rate of neoadjuvant chemoradiotherapy, short-term clinical outcomes, rate of curative resection and pathological evaluation. The short-term clinical outcomes are adverse events of neoadjuvant chemoradiotherapy and surgery-related complications. Thirty-five patients are required for this study.

Totally laparoscopic colectomy with intracorporeal anastomosis achieved using a laparoscopic linear stapler: experience of a single institute

PurposeLaparoscopic colonic surgery is now widely accepted. We assessed the safety and effectiveness of using a total intracorporeal surgical strategy to perform intracorporeal functional end-to-end anastomosis with an endoscopic linear stapler to treat colon cancer.MethodsForty-three selected patients underwent elective laparoscopic colon resection for carcinoma. A total intracorporeal colon resection was performed in all patients, using a functional end-to-end anastomosis with an endoscopic linear stapler.ResultsGood results were achieved in all 43 patients, none of whom required conversion to open surgery with extracorporeal anastomosis. There have been no intraoperative complications related to this technique and no instances of postoperative anastomotic leakage, intra-abdominal abscess, or wound infection.ConclusionIntracorporeal functional end-to-end anastomosis using a linear stapler can be performed safely and easily for the resection of any part of the colon. We consider it an effective modality for totally laparoscopic colon resection. Favorable results have been achieved by this method, particularly for small tumors, since natural-orifice transluminal endoscopic surgery remains a challenging method to perform.

Superficially spreading cancer of the stomach

BackgroundSuperficially spreading cancer (SSC) of the stomach is rare and extends widely along the mucosa or submucosa of the stomach. This study was conducted to clarify the clinicopathologic characteristics and prognosis of patients with SSC.MethodsSSC was defined as a tumor invading the mucosa or submucosa and measuring ≥5 cm in size. The clinicopathologic findings and outcomes of 36 patients with SSC were compared with those of 300 patients with early gastric cancer (EGC) measuring ≤5 cm and 271 with advanced gastric cancer measuring ≥5 cm.ResultsSSC was significantly different from ordinary EGC in tumor size, frequency of lymph node metastasis, lymphatic invasion, venous invasion, and stage II, III and IV disease. The frequency of serosal invasion, lymph node metastasis, and lymphatic and venous invasions in cases of SSC was significantly lower than with advanced gastric cancer. Although tumor size of SSC evaluated before operation was smaller than that on the resected specimen, the 10-year survival rate was not different between SSC and ordinary EGC.ConclusionsSSC was characterized by high frequency of lymph node metastasis and preoperative underestimation of tumor size. SSC should be treated by a gastrectomy and lymphadenectomy with sufficient resection margin.

Peroral placement of a self-expandable covered metallic stent using an overtube for malignant gastroduodenal obstructions

PurposeTo evaluate the technical feasibility and safety of overtube-guided covered metallic stent placement as palliative treatment for patients with inoperable malignant gastric outlet obstructions.MethodsTo relieve the symptoms of severe nausea and recurrent vomiting in five patients with inoperable gastric cancer, we used an overtube (Long overtube; Sumitomo Bakelite, Tokyo, Japan) to place largediameter, self-expandable, covered esophageal Ultraflex stents (inner diameter 22–28 mm, length 10 or 12 cm; Boston Scientific, Watertown, MA, USA). Success was defined both technically and clinically.ResultsThe stent placement was technically successful in all patients and resulted in improvement of symptoms in all five patients, four of whom were thereafter able to ingest solid food. The remaining patient, a 94-year-old man, was unable to ingest food because of dysmasesis. During the mean follow-up of 17 weeks, there was no stent reocclusion and no life-threatening complications developed.ConclusionsThe placement of a large diameter, self-expandable, covered esophageal stent using an overtube appears to be effective for the palliative treatment of malignant gastric outlet obstruction.