Yasuko Nakamura

Randomized Clinical Trial of the Effects of Perioperative Use of Immune-enhancing Enteral Formula on Metabolic and Immunological Status in Patients Undergoing Esophagectomy

BackgroundAlthough perioperative immune-enhancing enteral formula (IEEF) is effective to decrease the rate of infectious complications, it is not clear whether perioperative use of IEEF decreases the incidence of postoperative complications and improves clinical outcome in patients who have undergone esophagectomy. A prospective randomized clinical trial was performed to examine the effects of perioperative IEEF on nutritional and immunological status in patients with esophageal carcinoma who have been treated with esophagectomy.MethodsA total of 30 patients were randomly assigned to two groups, each receiving 3 days of preoperative and postoperative enteral nutrition through jejunostomy started within 24 h after operation, either with immune-enhancing enteral formula (group IEEF, nxa0=xa016) or with regular polymeric enteral formula (group C, nxa0=xa014). Preoperative and postoperative nutritional and immunological parameters and clinical outcome were examined.ResultsA significant increase in the serum concentration of ornithine was noted in group IEEF and it peaked at 5 days after surgery. The equivalent values were significantly lower in group C. There was no difference in serum dochosahexaic acid between the two groups. The n−3/n−6 fatty acid ratio in group IEEF was significantly higher than in group C at 7 days after surgery. Peripheral percent lymphocyte fraction and total lymphocyte count in group IEEF were both significantly higher than those in group C. While T cell fraction of peripheral lymphocytes in group IEEF at 3 days after surgery, B cell fraction in group IEEF at 5 and 7 days after surgery was significantly higher than those in group C, suggesting that perioperative IEEF caused a shift towards B cell proliferation.ConclusionsPerioperative use of IEEF caused a significant increase in the total lymphocyte count at 3 and 5 days after operation and caused a shift toward B cell proliferation, which may possibly be beneficial to decrease the incidence of postoperative infectious complications.

Psoas abscess and cellulitis of the right gluteal region resulting from carcinoma of the cecum

Although retroperitoneal or psoas abscess is an unusual clinical problem, the insidious and occult characteristics of this abscess sometimes cause diagnostic delays, resulting in considerably high morbidity and mortality. In particular, psoas abscess caused by perforated colon carcinoma is uncommon. We report a case of psoas abscess caused by a carcinoma of the cecum. A 72-year-old Japanese woman was admitted to our hospital, with pain in the right groin and buttock. The pain had appeared 6 months before admission, and the symptoms had then been relieved by oral antibiotics. On March 25, 1999, inflammatory signs in the right buttock indicated localized cellulitis, and incision and drainage was performed at a local hospital. The patient was referred to our hospital on the same day. On admission to our hospital, computed tomography (CT) scan revealed a thick right-sided colonic wall and enlargement of the right ileopsoas muscle. Barium enema and colonofiberscopy revealed an ulcerated tumor occupying the entire circumference of the cecum. A retroperitoneal abscess and fistula had been formed by the retroperitoneal perforation of cecum carcinoma: surgical resection was performed after remission of the local inflammatory signs. Operative findings indicated that the cancerous lesion and its surrounding tissues were firmly attached to the right iliopsoas and major psoas muscle, and en-bloc resection, including adjacent muscular tissue, was performed. The fact that carcinoma of the colon could be a cause of psoas abscess and cellulitis in the gluteal region should be considered when an unexplained psoas abscess is diagnosed.

Laparoscopy-assisted uncut Roux-en-Y operation after distal gastrectomy for gastric cancer

In order to prevent the Roux stasis syndrome that sometimes follows Roux-en-Y gastrojejunostomy after distal gastrectomy, a new type of reconstruction, called the uncut Roux-en-Y technique, has been reported. We successfully performed 42 laparoscopy-assisted uncut Roux-en-Y gastrojejunostomies. Here we describe our technique and the initial outcome.

Multiple perforated ulcers of the small intestine associated with allergic granulomatous angiitis: report of a case.

Although allergic granulomatous angiitis (AGA) is occasionally associated with gastrointestinal lesions, multiple perforated ulcers of the gastrointestinal tract are uncommon. We report herein a case of AGA associated with multiple perforated ulcers that erupted in the small intestine during corticosteroid therapy. A 31-year-old Japanese man was admitted to our hospital with epigastralgia, edema of the bilateral lower extremities, and general malaise. He had a persistent high fever, abdominal pain, and watery diarrhea. Laboratory data showed remarkable eosinophilia. The abdominal pain became exacerbated after the administration of oral prednisolone. Physical examination indicated positive signs of peritoneal irritation in the entire abdomen, and abdominal computed tomography scanning showed intra-abdominal free air, suggesting generalized peritonitis due to intestinal perforation. Laparotomy revealed multiple perforated ulcers in the jejunum and ileum. Histological examination indicated remarkable eosinophilic infiltration in the surrounding area of the small arteries and arterioles located in the submucosal layer, which was compatible with AGA. Although the association of intestinal perforation with AGA is relatively infrequent, intensive perioperative management is essential to ensure a favorable clinical outcome, particularly during the period on corticosteroid therapy.

Abdominal Wall Abscess Associated with Perforated Jejunal Diverticulitis: Report of a Case

We report a case of abdominal wall abscess caused by diverticulitis of the jejunum penetrating through the abdominal wall. A 53-year-old Japanese woman visited a local hospital complaining of abdominal pain and a mass in the left lower abdomen. An abdominal computed tomography scan showed a tumor with isodensity in the left lower abdominal wall. Magnetic resonance imaging showed a mass in the abdominal wall with isointensity in the T1-intensified image and high intensity in the T2-intensified images. The mass was heterogeneous inside and protruded partially toward the intraperitoneal cavity. Ultrasound examination showed a heteroechoic mass extending into the intraperitoneal cavity. Laparotomy revealed a tumor in the abdominal wall with a fistulous tract extending to the jejunum. We resected the abdominal wall tumor with partial resection of the small intestine. The resected specimen contained a tumor with a fistulous tract passing through the abdominal wall. Histological examination revealed remarkable infiltration of neutrophils and a bacterial mass in the abdominal wall tumor, with a fistulous tract connected to the area adjacent to the mesenteric border of the jejunum. These findings suggested that diverticulitis of the jejunum had penetrated through the abdominal wall, leading to the formation of an abscess. We report this case to highlight the need for complete gastrointestinal evaluation with gastrointestinal barium studies and imaging analysis to examine extension of intra-abdominal lesions in patients with an unexplained abdominal wall abscess.

Orotate phosphoribosyltransferase levels measured by a newly established enzyme‐linked immunosorbent assay in gastric carcinoma

A number of enzymes have been shown to be involved in the process of activation and/or degradation of 5‐fluorouracil (5‐FU), and are potential candidates for predicting chemosensitivity to 5‐FU. Among these, orotate phosphoribosyltransferase (OPRT EC 2.4.2.10) is a key enzyme related to the first‐step activation process of 5‐FU and has been shown to be an important enzyme that helps to predict sensitivity to 5‐FU and its related derivatives. We developed a new enzyme‐linked immunosorbent assay (ELISA) to accurately assess intratumoral activity of OPRT. A new sandwich ELISA was established using anti‐OPRT polyclonal antibodies obtained from the rabbit immunized with the recombinant human peptides of the OPRT molecule. OPRT levels were measured in eight human cancer xenografts and in 75 gastric cancer tissues using both a newly established ELISA and a conventional enzyme assay, using radiolabeled 5‐FU as a substrate. There was a significant correlation between OPRT levels measured by this ELISA and OPRT enzyme activity the in eight human cancer xenografts (r2 = 0.782) and gastric carcinoma tissue (r2 = 0.617). The ELISA system for OPRT requires a minimal amount of carcinoma tissue, making it an easy‐to‐use assay system to predict sensitivity to 5‐FU and its derivatives in gastric carcinoma. There was a significant correlation between tumor growth inhibition rates against the oral administration of oral‐uracil/tegafur (UFT) and OPRT enzyme activity in the human cancer xenografts (r2 = 0.574). These results suggest that this newly developed sandwich ELISA system for the quantification of OPRT levels is technically simple, feasible and a useful tool to predict sensitivity to fluoropyrimidine‐based anticancer chemotherapy in patients with gastric carcinoma and other cancers. (Cancer Sci 2006; 97)

Weekly administration of paclitaxel attenuated rectal stenosis caused by multiple peritoneal recurrence 8 years after the resection of gastric carcinoma.

We report a patient with rectal stenosis caused by peritoneal recurrence 8 years after a curative resection of advanced stage gastric carcinoma; the recurrence was effectively treated with the weekly administration of paclitaxel. The patient was a 66-year-old Japanese woman who was admitted to our hospital complaining of abdominal pain and frequent bowel movements. She had undergone total gastrectomy, due to advanced-stage gastric carcinoma with extensive lymph node metastasis, 8 years before, and had taken an oral anticancer agent, fluoropyrimidine, for 4 years after the operation. Colonofiberscopy performed on admission revealed circumferential rectal stenosis located 10u2009cm from the anal verge. Barium enema study demonstrated extensive poor expansion of the upper and lower rectum and irregularity of the descending colon. Abdominal computed tomography (CT) scanning revealed wall thickening in the rectum and descending colon. These findings were compatible with rectal stenosis caused by the peritoneal recurrence of gastric carcinoma. Weekly administration of paclitaxel was started. The abdominal symptoms soon disappeared when the second cycle of paclitaxel was completed, and they have not appeared since then. The rectal stenosis was attenuated, as confirmed by imaging analyses. Weekly paclitaxel has been effective for more than 13 months, suggesting that the patient is in a state of tumor dormancy of recurrent gastric carcinoma.

Esophageal duplication cyst continuously extending into the peritoneal cavity on the proximal portion of the stomach

Although bronchogenic or esophageal duplication cysts are foregut-derived developmental anomalies most commonly encountered in the mediastinum and rarely in the abdomen, a cyst continuously extending into the abdomen via the esophageal hiatus has not been reported previously. We report a case of esophageal duplication cyst that occurred in the distal esophagus and extended continuously into the proximal portion of the stomach via the esophageal hiatus. A 62-year-old Japanese man was admitted to a local hospital complaining of dysphagia and upper abdominal pain. Abdominal ultrasound and CT scan revealed a cystic mass dorsal to the lateral segment of the liver that extended continuously into the mediastinum via the hiatus. The upper gastrointestinal series and endoscopic examination revealed extramural compression of the distal esophagus without mucosal lesions. Resection of the cystic lesion was performed by thoracotomy followed by laparotomy. The upper part of the cyst originated in the submucosal layer, extending into the muscularis propria of the distal esophagus. Histology of the resected specimen indicated that the cystic wall was composed of two smooth muscle layers and that the inner cystic wall was lined with pseudostratified columnar ciliated and/or squamous epithelium associated without cartilage or respiratory gland, indicating esophageal differentiation. These histological characteristics indicated that the cyst was an esophageal duplication cyst, rather than a bronchogenic cyst. This is the first case of a large esophageal duplication cyst of the distal esophagus continuously extending into the abdomen via the esophageal hiatus. The atypical location of this esophageal duplication cyst provides an insight into the pathogenesis of esophageal duplication cysts.

Hemorrhagic radiation gastritis after chemoradiation therapy for peritoneal lymph node metastasis of esophageal carcinoma successfully treated with repeated intraarterial steroid infusions

Although intraarterial steroid infusion therapy has previously been shown to be effective for inflammatory bowel disease, it has not yet been applied for the treatment of hemorrhagic radiation gastritis. We report herein a case of hemorrhagic radiation gastritis of gastric tube that occurred after chemoradiation therapy for postoperative peritoneal lymph node metastasis in a patient with esophageal carcinoma who had a history of esophagectomy reconstructed with a gastric tube. The hemorrhagic gastritis that occurred in the gastric tube was successfully treated with repeated intraarterial steroid infusions through the regional vessels to the reconstructed gastric tube. A 70-year-old Japanese woman received chemoradiation therapy for metastatic lymph nodes of the celiac axis. Four weeks after completion of chemoradiation therapy, acute persistent bleeding occurred in the gastric mucosa of the reconstructed gastric tube in the irradiated area. Despite application of available therapeutic modalities, her persistent bleeding was intractable, and a total of 50 units of blood transfusion was required to improve progressive anemia. Finally, intraarterial steroid infusion therapy was applied through the right gastroepiploic artery supplying the main blood flow to the gastric tube. Three repeated intraarterial steroid infusions through the right gastroepiploic artery were effective, and hemostasis was finally completed soon after the last dose of intraarterial steroid was given. This case highlights the clinical importance and significance of hemorrhagic radiation gastritis of the reconstructed gastric tube with posterior mediastinal route occurring after chemoradiation therapy. Repeated intraarterial steroid infusion could be one option that appears clinically useful to treat intractable bleeding from radiation gastritis.

Acute upper gastrointestinal bleeding from multiple Barrett's ulcers associated with metachronous multiple colorectal carcinomas

Although gastroesophageal reflux disease is sometimes associated with esophageal ulcer and/or mucosal erosion, acute upper gastrointestinal bleeding from an esophageal ulcer is uncommon. We report a case of acute gastrointestinal bleeding from one of multiple esophageal ulcers in extensive Barretts esophagus in the postoperative period after low anterior resection performed for descending colon carcinoma. A 74-year-old Japanese woman had undergone sigmoid colon resection 6 years earlier. The patient had a history of repeated reflux esophagitis. She was referred to a local hospital for a simple health screening 5 years after surgery. The patient had noticed bloody stool and felt mild difficulty at defecation 2 weeks before admission. Lower gastrointestinal endoscopy performed at a local hospital revealed a type 2 tumor located approximately 15u2009cm from the anal verge, which was obviously the cause of the bloody stool and constipation. The patient was admitted to our hospital for surgical treatment. Ten days after the low anterior resection, upper gastrointestinal bleeding occurred. Upper gastrointestinal endoscopy revealed multiple ulcers in the lower esophagus, which had caused the bleeding. Endoscopic biopsy revealed that esophageal ulcer occurred in the Barretts esophagus, extending 15u2009cm from the functional esophagogastric junction. This case highlights acute upper gastrointestinal bleeding from multiple Barretts ulcers in extensive Barretts epithelium occurring in the postoperative period of colorectal carcinoma, and indicates an association of Barretts esophagus with metachronous multiple colon carcinoma.