Yuichi Arimoto

Endoscopic stenting versus surgical gastroenterostomy for palliation of malignant gastroduodenal obstruction: a meta-analysis

BackgroundWe attempted to elucidate the current status of endoscopic self-expanding metal stents for palliation of malignant gastroduodenal obstruction in comparison with surgical gastroenterostomy.MethodsOriginal articles and abstracts published from January 1990 to September 2006 were searched in Medline, EMBASE, and Cochrane Controlled Trials Register databases. Clinical appraisal and data extraction were independently conducted by two reviewers. Statistical analysis was performed by meta-analysis using a random effects model. Weighted mean differences with 95% confidence intervals (CI) were used to analyze continuous variables. Odds ratios with 95% CI were calculated for dichotomous variables.ResultsThe outcomes of 307 procedures from nine studies were analyzed. Endoscopic stenting was found to be associated with higher clinical success (P = 0.007), a shorter time from the procedure to starting oral intake (P < 0.001), less morbidity (P = 0.02), lower incidence of delayed gastric emptying (P = 0.002), and a shorter hospital stay (P < 0.001) than surgical gastroenterostomy. There was no significant difference between the two groups in the analysis of 30-day mortality.ConclusionsEndoscopic stenting may be a feasible alternative to surgery for the palliation of inoperable malignant gastroduodenal obstruction, with a high clinical success and low morbidity rate. Additional well-designed randomized controlled trials with larger sample sizes are expected to further reinforce this conclusion.

A Meta-Analysis of the Short- And Long-Term Results of Randomized Controlled Trials That Compared Laparoscopy-Assisted and Open Colectomy for Colon Cancer

Purpose: We conducted a meta-analysis to evaluate and compare the short- and long-term results of laparoscopy-assisted colectomy (LAC) and open colectomy (OC) for colon cancer. Methods: We searched MEDLINE, EMBASE, Science Citation Index, and Cochrane Controlled Trial Register for relevant papers published between January 1990 and October 2011 by using the search terms “laparoscopy,” “laparoscopy-assisted,” “surgery,” “colectomy,” “colon cancer,” and “randomized clinical trials (RCTs)”. We analyzed the outcomes of each type of surgery over short- and long-term periods. Results: We selected 12 papers reporting RCTs that compared LAC with OC for colon cancer. Our meta-analysis included 4614 patients with colon cancer; of these, 2444 had undergone LAC and 2170 had undergone OC. In the short-term period, we found that the rates of overall postoperative complications and ileus in LAC were lower than in OC groups. LAC was associated with a reduction in intraoperative blood loss, a shorter duration of time to resumption and hospital stay, and lower rates of overall complication and ileus over the short-term, but with similar long-term oncologic outcomes such as overall and cancer-related mortality, overall recurrence, local recurrence, distant metastasis, and wound-site recurrence, compared to OC. Conclusions: It is suggested that LAC may be preferred to OC for colon cancer.

Internal Hernia with Strangulation Through a Mesenteric Defect After Laparoscopy-Assisted Transverse Colectomy: Report of a Case

A 58-year-old woman underwent laparoscopy-assisted transverse colectomy for transverse colon cancer. On postoperative day 7, she experienced sudden abdominal pain accompanied by vomiting and fever. Computed tomography showed a small bowel obstruction caused by an internal hernia. Laparotomy revealed an internal hernia through the mesenteric defect at the anastomotic colonic stumps, which had not been closed in the previous operation. Almost the entire small bowel protruding through the mesenteric defect was found in the omental bursa. We resected part of the jejunal loop, which was strangulated and congested by an adherent band. Our experience suggests that if the mesenteric defect is relatively small, it should be closed completely during laparoscopy-assisted colectomy; however, more studies are required to determine the indications for closure of the mesenteric defect to prevent this complication.

Association of tumor cell proliferation with lymph node metastasis in early gastric cancer.

Recently, many studies have reported on the relationship between malignant potential of neoplasms and cell proliferation. Proliferating cell nuclear antigen (PCNA) is an auxiliary protein of DNA polymerase delta and is considered to correlate with the cells proliferative state. In this study, we investigated the correlation between tumor cell proliferation and nodal status of early gastric carcinoma. One hundred two endoscopically biopsied specimens from patients with early gastric carcinoma prior to operation were investigated by an immunohistochemical study, using anti-PCNA monoclonal antibody. Correlation of PCNA labeling index (percentage of positive cells per over 500 tumor cells) with nodal status were studied. PCNA labeling index in patients with lymph node metastasis was significantly higher in those without metastasis. Moreover, multivariate analysis indicated that PCNA labeling index is an independent significant factor for lymph node metastasis. As a result of this study, PCNA labeling index was suggested to be effective as one of the predictors of lymph node metastasis.

Percutaneous endoscopic gastrostomy, duodenostomy and jejunostomy.

Although enteral feeding by nasal gastric tube is popular for the patients who have a swallowing disability and require long-term nutritional support, but have intact gut, this tube sometimes causes aspiration pneumonia or esophageal ulcer. For these patients, conventional techniques for performance of a feeding gastrostomy made by surgical laparotomy have been used so far. However, these patients are frequently poor anesthetic and operative risks. Percutaneous endoscopic gastrostomy (PEG) which can be accomplished with local anesthesia and without the necessity for laparotomy has become popular in the clinical treatment for these patients. PEG was performed in 31 cases, percutaneous endoscopic duodenostomy (PED) in 1 case, and percutaneous endoscopic jejunostomy (PEJ) in 2 cases. All patients were successfully placed, and no major complication and few minor complications (9%) were experienced in this procedure. After this procedure, some patients could discharge their sputa easily and their pneumonia subsided. PED and PEJ for the patients who had previously received gastrostomy could also be done successfully with great care. Our experience suggests that PEG, PED, and PEJ are rapid, safe, and useful procedures for the patients who have poor anesthetic or poor operative risks.

A CASE OF RUPTURE OF A PTCD CATHETER IN THE BODY

症例は59歳, 男性. 全身倦怠感を主訴に当院内科を受診. 腹部CT検査にて膵頭部腫瘍, 閉塞性黄疸を指摘され, 加療目的に当科紹介となった. 減黄目的に心窩部からB2, B3合流部を穿刺し, PTCDカテーテル (7.2Fr, polyethylene) を挿入した. カテーテル留置後20日目, 誘因なく排液が途絶し, 腹部X線検査, 腹部CT検査にて体内でのカテーテルの断裂が認められた. われわれは, 同日緊急手術にてカテーテルの回収と予定していた膵頭十二指腸切除術を一期的に施行した. 手術所見では, カテーテルの瘻孔が形成されていたため腹腔内への胆汁漏出はなく, 膵頭十二指腸切除術を完遂し得た. カテーテルが断裂した原因の1つとして, カテーテルの呼吸性移動による剣状突起との摩擦があり, 材料疲労を起こした可能性が考えられた. PTCDの合併症としてカテーテル自体の断裂は極めて稀であるため, 若干の文献的考察を加えて報告する.

Outcome and Quality of Life of Repeat Liver Resection for Intrahepatic Recurrence of Hepatocellular Carcinoma after Hepatectomy

肝細胞癌 (以下, HCC) 切除後残肝再発に対する繰り返し肝切除例の臨床病理学的因子, 生存率, quality of life (以下, QOL) を検討した. 過去15年間に施行したHCC切除153例中73例 (48%) に残肝再発を認め18例 (25%) に延べ26回の繰り返し肝切除 (2回肝切除13例, 3回肝切除2例, 4回肝切除3例) を行った. 男性11例女性7例, 年齢は55～76歳 (平均68歳), ICG-R15値は3～37%(平均21%), 術式は亜区域以上の切除4回, 尾状葉全切除2回, 小範囲系統的切除18回, 核出2回であった. 切除腫瘍数は1～5個 (平均1.8個), 腫瘍径は0.7～4.4cm (平均2.0cm), 手術時間は240～660分 (平均430分), 出血量は500～4,600g (平均1,490g), 術後在院期間は11～50日 (平均26日) で耐術例は全例社会復帰しQOLは初回肝切除例と同等であった. 2回目肝切除時起算の5年生存率は67%で対象153例の1回目肝切除時起算の5年生存率50%と同等であった. HCC切除後残肝再発に対する繰り返し肝切除は短い在院期間で良好な予後とQOLが得られた. 切除可能例には繰り返し肝切除が第1選択の治療法と思われた.

Usefulness of Intraportal Ultrasonography in Diagnosis of Portal Vein Involvement in Pancreatobiliary Cancer.

膵胆道癌に対し細径超音波プローベを用いて門脈内超音波検査 (intraportal ultrasonography: 以下, IPUS) を行い, 癌の門脈浸潤を中心とした進展度診断への応用を試みた. 対象は膵胆道癌22例で, 経皮経肝門脈造影時に細径超音波プローベを門脈内に誘導し観察した. IPUSでは門脈壁は一層の高エコー帯として描出されるが, 門脈浸潤度診断はその高エコー帯の状態を観察することにより行い, IPUSV0～V3に分類した. 手術時の肉眼所見PV0～PV3と対比したところ18例中17例に一致をみた. 組織学的には, 門脈合併切除症例8例中7例において正診を得た. 門脈内の実質像を2例経験し, 1例は腫瘍栓であったが1例は血栓であった. 以上より, IPUSは膵胆道癌の門脈浸潤度診断に有用であり, 浸潤の有無とともにその程度も正確に診断しえた. しかし門脈内の実質像に対しては診断困難な症例を経験し今後の検討が必要であると考えられた.

Role of ELAM-1 Binding and Cytokines in Liver Metastasis of Pancreatic Cancer and Possible Therapeutic Application of a Glycosylation Inhibitor.

膵癌細胞を用い, 肝転移における糖鎖抗原発現, ELAM-1接着との関連, サイトカインの関与ならびに糖鎖合成阻害剤 (BZN) による転移抑制の可能性を検討した.SW1990は約90%と高率に肝転移をきたし, sialyl-Lea, Lex発現およびヒト臍帯血管内皮細胞 (HUVECs) ならびにELAM-1への接着性と相関した. 末梢血単核球とSW1990との混合培養にて, サイトカイン (TNF-α, IL-1β) の上澄み中への強い産生がみられ, 同上澄みにてHUVECs上にELAM-1の発現が誘導された.SW1990のBZN処理にて, 糖鎖抗原発現およびELAM-1接着, さらにヌードマウス脾内注射による肝転移は有意に抑制され, BZNの新しい転移抑制法としての応用の可能性が示唆された.