Yasuhiko Umehara

Elective laparoscopy for small bowel obstruction.

We performed elective laparoscopic adhesiolysis in 21 patients with small bowel obstruction. The procedure was completely laparoscopic or laparoscopy assisted in 17 patients, but 4 patients required full laparotomy due to internal hernia in 2, perforation of the small bowel associated with dense adhesions in 1, and carcinoma of the cecum in 1. In patients with a laparoscopic or laparoscopy-assisted procedure, the mean operating time, mean time until the return of bowel function, and mean postoperative stay were 94 minutes, 3.3 days, and 9.9 days, respectively. During follow-up for 14 to 44 months, 3 patients developed recurrent obstruction, 1 patient suffered from catheter-induced thrombosis, and 1 patient died from lung cancer. Elective laparoscopy can be performed safely and effectively in selected patients with intermittent small bowel obstruction.

Comparison of doubling times of serum carcinoembryonic antigen produced by various metastatic lesions in recurrent gastric and colorectal carcinomas

The authors measured the serial serum carcinoem‐bryonic antigen (CEA) levels in patients with recurrent gastric or colorectal carcinoma. Among the 45 patients with recurrent gastric carcinomas, those with lung me‐tastases showed the most prolonged CEA doubling time (CEA‐DT), followed by those with liver and peritoneal metastases, respectively. Of the 31 patients with recurrent colorectal carcinomas, those with local recurrence showed the most prolonged CEA‐DT, followed by those with lung, liver, and peritoneal metastases, respectively. A positive correlation was observed for gastric and colorectal carcinomas between CEA‐DT in patients with metastatic lesions and outcome (R=0.84 and 0.93, respectively). The results of the current study suggest that postoperative measurement of CEA‐DT is useful in the determination of region of recurrence of carcinoma, which would permit early surgery and chemotherapy. Measurement of CEA‐DT also may be helpful for the accurate determination of prognosis.

RELATIONSHIP BETWEEN PLASMINOGEN ACTIVATORS AND STOMACH CARCINOMA STAGE

The antigen levels of plasminogen activators (PAs), tissue-type PA (t-PA) and urokinase-type PA (u-PA), were measured in extracts from 30 gastric carcinomas and corresponding normal gastric mucosa. The t-PA level was significantly higher in normal mucosa than in cancer tissue, while the u-PA level was significantly higher in cancer tissue. The u-PA level increased with increasing tumor stage, and there was a significant difference between early and advanced cancer. The u-PA level also increased with the degree of nodal involvement, and it was higher in undifferentiated tumors than in well-differentiated ones. It was higher in cases with venous invasion, liver metastasis or peritoneal dissemination than in cases without these features.

Evaluation of an oleic acid water-in-oil-in-water-type multiple emulsion as potential drug carrier via the enteral route

A water-in-oil-in-water (W/O/W) emulsion composed of oleic acid was used as a carrier of carboxyfluorescein (CF)via the enteral route, as a model for future drug transport. The absorption of CF in the small intestine of rats given the emulsion (W/O/W group) was compared with the absorption in a group administered CF alone (CF group), and a surface-active agent in CF solution (MM group). Higher amounts of CF were absorbed in the W/O/W and MM groups than in the CF group. At 120 min, the amount of CF remaining in the intestinal tract was smaller in the MM group than in the W/O/W group. In the early period, CF excretion into bile was higher in the MM group than in the W/O/W group was higher than in the MM group (non-specific). The blood CF level was significantly higher at 240 and 360 min in the W/O/W group than in the other two groups. The highest concentration in lymph was found in the W/O/W group. The W/O/W emulsion was considered superior to the micelles because it maintained a higher blood level of CF over long periods and transferred it to the lymph. This suggests that the W/O/W emulsion is applicable as a drug carriervia the enteral route.

Periodic measurement of serum carcinoembryonic antigen and carbohydrate antigen 15-3 levels as postoperative surveillance after breast cancer surgery.

PurposeBreast cancer surveillance guidelines do not recommend routine tumor marker testing after surgery, despite which it is still widely performed in Japan. We investigated the clinical utility of postoperative tumor marker testing in a series of Japanese patients, in view of the fact that all the studies to date have been non-Japanese.MethodsWe retrospectively analyzed the lead time by periodic measurements of serum carcinoembryonic antigen (CEA) and carbohydrate antigen 15-3 (CA15-3) in 233 patients who underwent breast cancer surgery. Both tumor marker levels were measured every 3 months for the first 5 years, every 6 months for the next 5 years, then annually. Physical examination and chest X-ray were routinely done at the same time, and bone or computed tomographic scans were done if the tumor marker levels were elevated or clinical symptoms appeared.ResultsIn patients with recurrent disease, the mean lead times were −333.9 days for CEA and −210.6 days for CA15-3, respectively. Elevated tumor marker levels were found much later than recurrence.ConclusionOur results support the American Society of Clinical Oncology guidelines. Thus, the serial testing of tumor marker levels after breast cancer surgery may not be as beneficial as thought in Japan.

Long-term survival after report resection of pulmonary metastases from hepatocellular carcinoma: report of two cases.

Hepatocellular carcinoma (HCC) is often treated most effectively by resection. Although improved surgical procedures and perioperative care have made hepatic resection safe, the prognosis of patients with HCC is still poor because of the high incidence of postoperative recurrence. The most common site of extrahepatic recurrence is the lung. However, because of its multiplicity and concurrent recurrence in the liver remnant, resection of pulmonary metastases form HCC is rarely beneficial. We report two cases of long-term survival after repeated pulmonary resection of metastasis from HCC. At the time of this report the two patients were free of disease, 110 months and 107 months, respectively, after their initial hepatectomy. These case reports show that pulmonary metastases from HCC can be successfully resected in selected patients.

Gastric carcinoma resembling submucosal tumor

Abstract:A case of stomach carcinoma showing features of submucosal tumor is reported. The patient was a 50-year-old man presenting with hematemesis. Endoscopic examination was performed and revealed a submucosal tumor-like lesion with central ulceration in the fornix of the stomach. The biopsy specimen from this lesion showed poorly differentiated adenocarcinoma, and surgery was performed. The tumor, measuring 3.5 × 2.7 cm in size, invaded to the muscularis propria with proliferation of the interstitial connective tissue and lymphoid follicles consisting mainly of B lymphocytes in the submucosal layer. In situ hybridization of tumor tissue for Epstein-Barr virus (EBV)-encoded small RNA1 as target revealed negative results. In stomach carcinoma simulating submucosal tumor, as in this patient, preoperative diagnosis is important to plan treatment strategies.

Metastatic mode of gastric carcinoma by flow cytometric and clinicopathologic parameters

We used flow cytometric and conventional clinicopathologic parameters to analyse the metastatic mode of cancer in 113 stomach cancer patients. Liver metastasis was frequent in cases with intestinal-type cancer, cancer located in the distal stomach, positive venous invasion and aneuploid cancer. Lung and pleural metastasis (excluding nodular lung metastasis), however, were frequent in cases with serosal invasion and diploid cancer. Peritoneal metastasis was frequently seen with tumors located in the proximal or whole stomach, diffuse-type cancer and cancer with serosal invasion. All cases developing bone metastasis were positive for lymph node metastasis. DNA ploidy was partially related to the metastatic mode of stomach cancer, but this was not the sole parameter for predicting metastasis. However, prediction may be possible if based on both DNA ploidy and clinicopathologic parameters, suggesting the possibility of the prophylaxis of recurrence by appropriate postoperative adjuvant therapy.

Laparoscopic ultrasonography and operative cholangiography prevent residual common bile duct stones in laparoscopic cholecystectomy.

We retrospectively evaluated the role of intraoperative cholangiography (IOC) combined with laparoscopic intraoperative ultrasonography (LIOU) for detection of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy. We reviewed 184 patients with biliary stones. Preoperatively, all patients underwent ultrasonography (US); 183 of the patients were investigated by cholangiography (oral and intravenous cholangiography in 145 and endoscopic retrograde cholangiography in 44). LIOU was carried out in all patients and IOC was done in 183. LIOU visualized the bile duct in 94.6% of the patients and IOC was successful in 95.6%. CBD stones were detected in a total of 17 patients, 9 (52.9%) of whom were positive on preoperative investigations. The sensitivity for detecting CBD stones was 29.4% with US, 22.2% with oral and intravenous cholangiography, 50.0% with endoscopic retrograde cholangiography, 82.4% with LIOU, and 93.3% with IOC. The diameter of the stones visualized intraoperatively (4.4 +/- 1.2 mm) was smaller than that of the stones detected preoperatively (6.9 +/- 2.6 mm). The stones were removed during laparoscopy in 15 patients and after conversion to laparotomy in 2. None of the patients had residual CBD stones after follow-up for 6 to 50 months. Intraoperative examination using both LIOU and IOC was useful for prevention of residual CBD stones.

Metastatic mode and DNA ploidy in gastric carcinoma

We studied the amounts of nuclear DNA in gastric cancer metastases histologically and cytochemically by flow cytometry, which was performed retrospectively on paraffin-embedded specimens from 95 patients. At surgery, all cases of aneuploid cancer were positive for lymph node metastases. Liver metastases were frequently seen in aneuploid cancer (63%, P<0.01), while lung metastases were the most common in diploid cancer (50%, P<0.05). The incidence of peritoneal metastasis was high in undifferentiated diploid cancer (72%, P<0.01). Local lymph node recurrence after surgery was more common in aneuploid than in diploid cancer (P<0.01). The incidence of bone and distant lymph node metastasis was found to be strongly dependant on tissue differentiation. The DNA ploidy pattern is thus considered to be closely linked to lymph node, liver, and lung metastases in gastric cancer.