Preoperative mechanical bowel preparation using conventional versus hyperosmolar polyethylene glycol-electrolyte lavage solution before laparoscopic resection for colorectal cancer (TLUMP test): a phase III, multicenter randomized controlled non-inferiority trial.

BACKGROUND: A hyperosmolar ascorbic acid-enriched polyethylene glycol-electrolyte (ASC-PEG) lavage solution ensures excellent bowel preparation before colonoscopy; however, no study has demonstrated the efficacy of this lavage solution before surgery. This study aimed to establish the non-inferiority of ASC-PEG to the standard polyethylene glycol-electrolyte solution (PEG-ELS) in patients undergoing laparoscopic resection for colorectal cancer. METHODS: This was a prospective, single-blind, multicenter, randomized, controlled, non-inferiority clinical trial. Overall, 188 patients scheduled for laparoscopic colorectal resection for single colorectal adenocarcinomas were randomly assigned to undergo preparation with different PEG solutions between August 2017 and April 2020 at four hospitals in Japan. Participants received ASC-PEG (Group A) or PEG-ELS (Group B) preoperatively. The primary endpoint was the ratio of successful bowel preparations using the modified Aronchick scale, defined as "excellent" or "good." RESULTS: After exclusion, 86 and 87 patients in Groups A and B, respectively, completed the study, and their data were analyzed. ASC-PEG was not inferior to PEG-ELS in terms of effective bowel preparation prior to laparoscopic colorectal resection (0.93 vs. 0.92; 95% confidence interval, - 0.078 to 0.099, p = 0.007). The total volume of cleansing solution intake was lower in Group A than in Group B (1757.0 vs. 1970.1 mL). Two and three severe postoperative adverse events occurred in Groups A and B, respectively. Patient tolerance of the two solutions was almost equal. CONCLUSIONS: ASC-PEG is effective for preoperative bowel preparation in patients undergoing laparoscopic resection for colorectal cancer and is non-inferior to PEG-ELS.

The survival impact of preoperative FOLFOX for resectable locally advanced rectal cancer: the R-NAC-01 study.

PURPOSE: In this follow-up of the R-NAC-01 study, we assessed the long-term oncological benefit of four courses of modified leucovorin, 5-fluorouracil (FU), and oxaliplatin (mFOLFOX6) chemotherapy before rectal surgery. METHODS: In this prospective, multicenter study (UMIN 000012559) involving 11 hospitals in Japan, patients with lower rectal cancer underwent four cycles of mFOLFOX6 chemotherapy and subsequent surgery within four to six weeks. The 3-year recurrence-free survival and local recurrence rates were then reported. RESULTS: Of 41 patients (36 males, 5 females; mean age: 60.8 years old) who received 4 courses of chemotherapy, 40 underwent total mesorectal excision, and 1 underwent total pelvic exenteration. R0 resection was achieved in 40 patients, but none showed a pathological complete response. Twenty-nine patients received adjuvant chemotherapy for an average of 4 months. The 3 year recurrence-free survival and local recurrence rates in patients undergoing curable resection were 72.8% and 8.5%, respectively. cStage III patients with adjuvant chemotherapy had a significantly higher 3 year recurrence-free survival than those without adjuvant chemotherapy (76.6 vs. 40.0%, log-rank p = 0.03). CONCLUSION: Four courses of mFOLFOX6 chemotherapy before surgery may be a promising treatment strategy for locally advanced rectal cancer. Adjuvant chemotherapy might be needed for cStage III patients, even after four courses of neoadjuvant mFOLFOX6.

Non-destructive assessment of amylose content in rice using a quality inspection system at grain elevators.

Amylose content is an important determinant of rice quality. Its accurate, non-destructive assessment is a challenge to the industry. We examined whether the automatic quality inspection system accurately measured the amylose content. Brown and milled rice models were calibrated with 902 samples produced between 2008 and 2017 in Hokkaido, Japan, and validated individually by samples collected in 2018 (n = 33) and 2019 (n = 71) from several grain elevators within the region. Models were developed by processing the automatic system data comprising of a near-infrared spectrometer, a visible light grain segregator, combined analysis of chemometrics, and by merging low and ordinary amylose variety validation results. The lower standard error of prediction (<0.52%) and a higher ratio of performance deviation (>4.0) in both models enabled accurate non-destructive assessment of amylose content. Hence, the automatic quality inspection system is a useful tool for meeting the demands of higher quality and palatability of rice.

Portal Annular Pancreas With Common Hepatic Artery Trajectory Abnormality: A Case Report and Review of the Literature.

ABSTRACT: Portal annular pancreas (PAP) is a rare congenital pancreatic anomaly, in which the uncinate process of the pancreas fuses to the body of pancreas behind the portal vein. Here, we report a case of PAP with common hepatic arterial anomaly, which was identified during surgery. A 57-year-old man who had branch type intraductal papillary mucinous neoplasm in the head of the pancreas developed a nodule in the cystic lesion. We planned pylorus preserving pancreaticoduodenectomy. The common hepatic artery from the celiac artery passing behind the portal vein was revealed in preoperative examinations. During surgery, we discovered that the uncinate process of the pancreas was fused with the body of the pancreas behind the portal vein. We divided the pancreas at the anterior and posterior of the portal vein. The main pancreatic duct was present in the anterior pancreatic stump. We performed pancreaticojejunostomy in the anterior stump and closed the posterior stump by interrupted suture. Forty-four surgical cases of PAP have been reported in the English medical literature. There are few previous reports of PAP which involved an arterial anomaly. Clinicians should consider PAP preoperatively to ensure that the surgeon can appropriately plan pancreatic resection to avoid postoperative complications.

Short-term and Long-term Outcomes Following Laparoscopic Gastrectomy for Advanced Gastric Cancer Compared With Open Gastrectomy.

INTRODUCTION: To investigate the oncological feasibility and technical safety of laparoscopic gastrectomy with D2 lymphadenectomy for advanced gastric cancer. METHODS: A total of 186 advanced gastric cancer patients treated by gastrectomy with D2 lymphadenectomy were eligible for inclusion including those with invasion into the muscularis propria, subserosa, and serosa without involvement of other organs, and stages N0-2 and M0. We retrospectively compared the short-term and long-term outcomes between laparoscopic gastrectomy and open gastrectomy. RESULTS: We analyzed short-term outcomes by comparing distal with total gastrectomy results. We found no significant difference for distal gastrectomy for postoperative morbidity [laparoscopic vs. open: n=4 (4.6%) vs. n=1 (3.6%); P=1.00]. We also found no significant difference in postoperative morbidity for total gastrectomy [laparoscopic vs. open: n=2 (4.0%) vs. n=1 (4.0%); P=1.00]. No deaths occurred in any group.The entire cohort analysis revealed no statistically significant differences in overall-free or recurrence-free survival between the laparoscopic and open groups. For overall survival, there were no significant differences between open and laparoscopic groups for clinical stage II or III (P=0.29 and 0.27, respectively), and for pathologic stage II or III (P=0.88 and 0.86, respectively). For recurrence-free survival, there were no significant differences between open and laparoscopic groups for clinical stage II or III (P=0.63 and 0.60, respectively), and for pathologic stage II or III (P=0.98 and 0.72, respectively). CONCLUSION: Laparscopic gastrectomy for advanced gastric cancer compared favorably with open gastrectomy regarding short-term and long-term outcomes.

Preoperative FOLFOX in resectable locally advanced rectal cancer can be a safe and promising strategy: the R-NAC-01 study.

PURPOSE: The aim of this study was to assess the safety of rectal surgery after 5-fluorouracil-leucovorin-oxaliplatin chemotherapy (FOLFOX6). METHODS: This was a prospective, multicenter study in 11 Japanese hospitals. We included patients with rectal cancer who received 4 courses of modified FOLFOX6 (mFOLFOX6) before rectal surgery and examined the postoperative complication rate, the clinicopathological response, and the rate of chemotherapy-related adverse events (UMIN 000012559). RESULTS: The study population included 36 men and 5 women. The average age of the patients was 60.8 years and the average body mass index was 23.1 kg/m2. After 4 courses of chemotherapy, grade 2 peripheral nerve disorder and other grade 3 adverse events were seen in 3 patients each (7.3%). Twenty-eight (73.7%) and 8 (21.1%) patients underwent low anterior resection and abdominoperineal resection, respectively. The pelvic nerves were preserved in 35 patients. Surgical morbidity (grade ≥ 3) occurred in 4 patients (10.5%). Anastomotic leakage occurred after surgery in 2 patients (7.1%). No patients achieved pathologically complete remission. However, downstaging of the clinical stage and N stage was seen in 17 (41.5%) and 22 (53.7%) patients, respectively. CONCLUSIONS: Surgery after four courses of mFOLFOX6 chemotherapy can be a safe and promising strategy for patients with locally advanced rectal cancer.

[Laparoscopic Gastrectomy for Gastric Adenocarcinoma of the Fundic Gland Type].

Case 1: A 66-year-old man underwent esophagogastroduodenoscopy(EGD), which showed a slightly elevated lesion at the greater curvature of the cardia. We diagnosed gastric adenocarcinoma(tub1, 2)as a result of the biopsy. Endoscopic submucosal dissection(ESD)was performed. The pathological examination revealed a gastric adenocarcinoma of the fundic type(GA-FG), with a tumor depth of SM2. Consequently, laparoscopic gastrectomy was additionally performed. Case 2: A 65-year-old woman underwent EGD, which revealed a slightly elevated lesion at the posterior wall of the upper body. We made a diagnosis of GA-FG as on the basis of biopsy resuit. ESD was performed. A pathological examination revealed that the tumor depth was SM2. Consequently, laparoscopic gastrectomy was additionally performed. GA-FG rarely demonstrates metastasis and recurrence. Most cases undergo ESD, few reports of surgical resection exist. We report our experience of laparoscopic gastrectomy for GA-FG.

[The Clinical Effect of Ramucirumab in the Treatment of Advanced Gastric Cancer in Our Hospital].

Ramucirumab(RAM)was approved for unresectable advanced gastric cancer in March 2015. Recent Japanese gastric cancer treatment guidelines recommended RAM plus paclitaxel(PTX)and RAM alone in the treatment of patients with advanced gastric cancer who had been previously treated with chemotherapy. In this retrospective study, we evaluated the safety and efficacy of RAM alone and PTX plus RAM in these patients. Patients who were administered RAM or PTX plus RAM between March 2015 and December 2016 were enrolled in this study. We compared the clinical outcome of RAM alone(RAM group, n=11)with that of PTX plus RAM(PTX plus RAM group, n=10). The RAM group contained more patients with poor performance status than the PTX plus RAM group. More cases of Grade 3 or 4 adverse events were found in the PTX plus RAM group than in the RAM group. The response rate was 9% in the RAM group and 30% in the PTX plus RAM group. The progression-free survival was 2 months in the RAM group and 3.75 months in the PTX plus RAM group. The overall survival was not reached in the RAM and PTX plus RAM groups. We considered that RAM and PTX plus RAM are safe and effective therapies for advanced gastric cancer patients.

Comparison of anatomic and non-anatomic hepatic resection for hepatocellular carcinoma.

BACKGROUND: The aim of the present study was to compare the prognostic impact of anatomic resection (AR) versus non-anatomic resection (NAR) on patient survival after resection of a single hepatocellular carcinoma (HCC). METHODS: To control for confounding variable distributions, a 1-to-1 propensity score match was applied to compare the outcomes of AR and NAR. Among 710 patients with a primary, solitary HCC of <5.0 cm in diameter that was resectable by either AR or NAR from 2003 to 2007 in Japan and Korea, 355 patients underwent NAR and 355 underwent AR of at least one section with complete removal of the portal territory containing the tumor. RESULTS: Overall survival (OS) was better in the AR than NAR group (hazard ratio 1.67, 95% confidence interval 1.28-2.19, P < 0.001) while disease-free survival showed no significant difference. Significantly fewer patients in the AR than NAR group developed intrahepatic HCC recurrence and multiple intrahepatic recurrences. Patients with poorly differentiated HCC who underwent AR had improved disease-free survival and OS. CONCLUSIONS: Anatomic resection decreases the risk of tumor recurrence and improves OS in patients with a primary, solitary HCC of <5.0 cm in diameter.

[Analysis of Oxaliplatin Combination Therapy for Unresectable or Recurrent Gastric Cancer].

We analyzed 26 cases of unresectable or recurrent gastric cancer treated with oxaliplatin(OX)combination therapy between September 2014 and January 2016. The number of unresectable gastric cancer cases was 14 and there were 12 recurrent cases. The number of patients receiving S-1 plus OX(SOX), SOX plus trastuzumab(Tmab), capecitabine(Cape)plus OX(CapeOX), and CapeOX plus Tmab was 17, 1, 6, and 2, respectively. The starting dose of OX was 130mg/m2 in 12 patients and 100mg/m2 in 14. The median follow-up duration from the first treatment was 6 months(1-14). The median number of treatment cycles was 5(1-19). Dose reductions occurred in 14 cases, and treatment delay occurred in 13 cases. Grade 3 adverse events occurred in 2 cases(8%); thrombocytopenia and stomatitis occurred in 1 case. The response rate was 23%, the disease control rate was 69%, and the median relapse-free survival time was 4 months(1-14). OX combination therapy for unresectable or recurrent gastric cancer was feasible in terms of safety and might be effective for disease control.

[A Case of Goblet Cell Carcinoid of the Appendix Invading Directly into the Sigmoid Colon].

A 73-year-old man underwent a screening colonoscopy, and a depressed lesion in the sigmoid colon was detected. Biopsy revealed a Group V lesion, and he was diagnosed with sigmoid colon cancer. During surgery, there was dense adhesion of the appendix to the sigmoid colon, and sigmoidectomy combined with appendectomy was performed. However, pathological examination revealed goblet cell carcinoid of the appendix with direct invasion into the sigmoid colon. To the best of our knowledge, no similar cases have been reported in Japan. Additional surgery with lymph node dissection was recommended, but it was rejected by the patient. For adjuvant chemotherapy, a total of 8 courses of capecitabine plus oxaliplatin therapy were administered. To date, the patient is alive without recurrence 2 years postoperatively. Postoperative adjuvant chemotherapy for goblet cell carcinoid of the appendix is a useful option for cases in which additional surgery cannot be performed.

ZEB1 expression is associated with prognosis of intrahepatic cholangiocarcinoma.

BACKGROUND/AIM: Intrahepatic cholangiocarcinoma (ICC) is one of the most aggressive malignant tumours, so the identification of molecular targets for ICC is an important issue. Zinc finger E-box binding homeobox 1 (ZEB1) is a key inducer of epithelial-mesenchymal transition (EMT). The aim of the present study was to clarify the clinical significance of ZEB1 in ICC and the associations between ZEB1 expression and EMT-related proteins. METHODS: We immunohistochemically examined the expression of EMT-related proteins, namely ZEB1, vimentin and E-cadherin, in ICC specimens from 102 patients. The clinicopathological and prognostic values of these markers were evaluated. RESULTS: ZEB1 and vimentin were expressed in 46.1% and 43.1% of tumours, respectively, and E-cadherin expression was lost in 44.1% of tumours. ZEB1 expression showed a significant inverse correlation with E-cadherin expression (p=0.004) and a positive correlation with vimentin expression (p=0.022). Altered expression of ZEB1 was associated with aggressive tumour characteristics, including advanced tumour stage (p=0.037), undifferentiated-type histology (p=0.017), lymph node metastasis (p=0.024) and portal vein invasion (p=0.037). Moreover, overall survival rates were significantly lower for patients with high ZEB1 expression than for patients with low ZEB1 expression (p=0.027). Kaplan-Meier analysis also identified E-cadherin expression (p=0.041) and vimentin expression (p=0.049) as prognostic indicators for overall survival. CONCLUSIONS: ZEB1 expression is associated with tumour progression and poor prognosis in patients with ICC through positive correlations with vimentin and negative correlations with E-cadherin. ZEB1 expression is associated with a poor prognosis and might be an attractive target for the treatment of ICC.

Dramatic resolution of bullous pemphigoid after surgery for gastric cancer: A case report.

INTRODUCTION: An association between bullous pemphigoid (BP) and internal malignancy has been suggested. However, no reports have documented a dramatic improvement in BP after surgery for gastric cancer. PRESENTATION OF CASE: An 82-year-old Japanese woman was admitted to a local hospital for severe fatigue. On examination, she was diagnosed with BP and gastric cancer. Her BP was resistant to steroid treatment; however, it improved dramatically after surgery for gastric cancer. DISCUSSION: In this case, a strong relationship appeared to exist between BP and gastric cancer. CONCLUSION: This is the first report of a dramatic improvement in BP after surgery for gastric cancer.

[Adjuvant chemotherapy with capecitabine for colon cancer - a case series].

We examined the treatment condition; adverse events, especially hand-foot syndrome (HFS); and prognosis in 65 patients with colon cancer who received adjuvant chemotherapy with capecitabine. The treatment completion rate was 75.4%; however, only 15.4% of patients completed treatment without dose reduction or treatment interruption. HFS occurred in 78.5% of all cases. The 3-year relapse-free survival rate was 73.8% for all cases, 80.8% for treatment-completed cases, and 51.1% for treatment-discontinued cases; however, there were no differences in relapse-free survival rates for cases that required dose reduction or treatment interruption. We conclude that adjuvant chemotherapy with capecitabine is effective in colon cancer and that completing treatment (even with dose reduction or dose interruption) improves prognosis.

[A case of an elderly patient with recurrent GIST, which was effectively treated with low-dose imatinib mesylate].

The recommended dose of imatinib for recurrent gastrointestinal stromal tumors (GIST) is 400mg/day. However, adverse effects limit the use of the standard dose in elderly patients. We report a case of an elderly patient with recurrent GIST, where long-term control of the disease was achieved with low-dose imatinib therapy. An 86-year-old man presenting with tarry stool was admitted to the hospital; upper GI endoscopy revealed a gastric submucosal tumor of the stomach at the posterior wall of the cardia. Partial gastrectomy was performed laparoscopically. The submucosal lesion was histopathologically diagnosed as malignant GIST. Administration of imatinib was initiated 17 months after surgery because of recurrence of GIST. The initial dose of imatinib was 400mg/day, which was later adjusted to 200mg or 300 mg/day because of adverse effects. Though imatinib was withdrawn several times due to strong side effects, the disease was well controlled for 6 years after surgery.

Background suppression in synthesized pulse waveform by feedback control optimization for flatly broadened supercontinuum generation.

We demonstrate a method of background component suppression of synthesized pulses for flatly broadened supercontinuum (SC) generation. An adaptive pulse shaping in frequency domain achieved a 26 dB contrast between pulse center and background level in auto-correlation trace by combining two fitness functions during feedback-controlled pulse shaping. The pulse was used as a SC pump, and the spectral peak of the SC at the pump wavelength was suppressed by 5 dB using the combination scheme. Simulation results show that the phase spectra control is required to be within ± π/100 rad to suppress the spectral peak below 3 dB. The results show that adaptive pulse shaping is required to improve SC flatness due to the small mismatch tolerance.

[A resected case of recurrent intrahepatic cholangiocellular carcinoma with a cholangiocellular carcinoma component after transcatheter arterial embolization and radiofrequency ablation].

We report a resected case of intrahepatic cholangiocarcinoma (ICC) with a cholangiolocellular carcinoma (CoCC) component. A 77-year-old man had been followed up regularly for chronic hepatitis C for 20 years. In April 2008, a hepatic tumor of 30-mm diameter was detected in segment 2 by computed tomography scan. The tumor was enhanced in the early phase and the enhancement was prolonged. He was treated with transcatheter arterial embolization following the diagnosis of hepatocellular carcinoma (HCC). He had a local recurrence in the same segment (S2) in March 2009, and transcatheter arterial embolization and radiofrequency ablation were performed. In March 2011, abdominal dynamic computed tomography and magnetic resonance imaging showed a sectoral lesion in S2/4 with early and prolonged enhancement. Following the preoperative diagnosis of local recurrence of HCC, he underwent left lobectomy of the liver. Histopathologically, strongly atypical glandular epithelial cells and mucin production were observed, and these cells grew invasively into the liver parenchyma. Furthermore, tumor cells in the peripheral area grew and replaced adjacent hepatic cells, and anastomosing cavities of glands were found on the gitter stein. For these reasons, the histopathological diagnosis was ICC with a CoCC component.

[A case in which a mucin-producing papillary adenocarcinoma of the gallbladder was resected].

An 81-year-old man complaining of abdominal pain underwent ultrasonography at another hospital that revealed gallbladder swelling, and he was admitted to our hospital for further examination. CT and ERCP revealed a papillary tumor extending from the body to the fundus, leading to the diagnosis of gallbladder cancer. Other examinations showed no sign of invasion or lymph node metastases. We performed full-thickness cholecystectomy. The histopathological diagnosis was mucin-producing papillary adenocarcinoma(T1N0M0, Stage I) of the gallbladder.

[A case report of goblet cell carcinoid tumor of the appendix].

Goblet cell carcinoid (GCC) tumor of the appendix is rare, and the prognosis is considered poor compared to classical carcinoid tumor. We present a case of a 60-year old woman who underwent appendectomy for acute appendicitis. Histopathological studies revealed a GCC tumor with submucosal invasion. Based on the malignancy of this tumor and the possible risk of regional lymph node metastases, we performed laparoscopic ileocecectomy with lymph node dissection. Histologically, no residual tumor or lymph node metastases were found. The patient remains well without any sign of recurrence.