Laparoscopy-assisted combined resection for synchronous gastric and colorectal cancer: report of three cases.

In gastric cancer patients, the most common form of synchronous cancer is colorectal cancer. To reduce the invasiveness of the resection, a laparoscopy-assisted combined resection was performed in three patients with synchronous gastric and colorectal cancer. Although all gastric lesions were in the early stages, two colorectal lesions were advanced cases. In all cases, the laparoscopic gastric resection and reconstruction was performed first, followed by the colorectal resection. In the case of right-side colon cancer in addition to gastric cancer, it was relatively easy to perform the combined resection with lymph node dissection sharing the same ports used for the gastrectomy, although we needed an additional port. In one case, in which rectal cancer was present in addition to gastric cancer located in the upper portion of the stomach, a totally laparoscopic proximal gastrectomy was combined with a laparoscopy-assisted low anterior resection, leaving only a lower abdominal minilaparotomy wound. All patients quickly returned to normal activity without remarkable complications, with the exception of a wound infection in one patient. With a mean follow-up of 30.7 months, all patients survived without any sign of recurrence. This procedure represents a feasible option for minimally invasive treatment of synchronous gastric and colorectal cancer.

New method of laparoscopic incisional hernia repair with double circumferential transfascial sutures.

BACKGROUND: Although, laparoscopic incisional hernia repair (LIHR) provides an alternative method for managing incisional hernias, the ideal procedure for reducing the incidence of postoperative complications remains unclear. PATIENTS AND METHODS: We have developed a new method of LIHR that involves a double transfascial suture and does not require the use of spiral tackers. We performed this procedure consecutively in five patients (four males and one female with a mean age of 65.6 years). We describe our new method of LIHR, and present preliminary clinical results. RESULTS: The mean defect size was 26.2 ± 15.8 cm(2), and the mesh size that was used was 121.7 cm(2) in all cases. An occult hernia was found in one patient during laparoscopic observation. The mean operative time was 198.4 ± 49.3 minutes with a blood loss of 12.2 ± 24.6 mL. Postoperative courses were uneventful with a median postoperative hospitalization period of 8 days. No patient required mesh removal and none developed a recurrent hernia during the median follow-up period of 13 months. CONCLUSION: Although, larger number of patients and longer follow-up will be required to prove the operative adequacy of our new procedure, it appears to represent a feasible option for LIHR.

Endoscopy-assisted totally laparoscopic resection of a submucosal tumor of the duodenum.

Although, endoscopic polypectomy is one of the first options for diagnosis and treatment of submucosal tumors of the duodenum, it is sometimes difficult for large or sessile tumors. Therefore, local excision or more extended surgery is performed under open laparotomy. In this paper, we present a laparoscopic resection of Brunner's gland hyperplasia of the duodenum which demonstrated rapid interval size change. A 73-year-old male with a histologically unproven submucosal tumor underwent endoscopy-assisted laparoscopic resection of the tumor and intracorporeal suturing of the defect. Simultaneous duodenoscopy and laparoscopy were performed to identify the line of resection. A duodenotomy was performed and the tumor was excised after everting the tumor toward the abdominal cavity. The defect was handsewn with the greater curvature side rolled caudally with an exteriorized stay suture. Postoperative pain was minimal and the patient quickly returned to normal activity. Our new technique provides a minimal invasive treatment for tumors of the duodenum.

Preliminary study comparing diffuse gastric FDG uptake and gastritis.

Diffuse high FDG uptake in the stomach is occasionally observed on positron emission tomography (PET) images. Some PET oncologists believe this to be physiologic uptake, but the exact cause is undetermined. We retrospectively compared PET images and endoscopic findings to examine the relation between diffuse gastric FDG uptake and gastritis. From September to December 2005, 113 individuals (68 men and 45 women), aged 52 ± 12 years, underwent both gastrofiberscopy and PET/computed tomography on the same day as part of a cancer screening program. Gastric FDG uptake was visually evaluated on PET images and classified as low, moderate, or high. Gastritis was classified as mild, moderate, or severe. For each screenee, the degree of FDG uptake was compared with the severity of gastritis. FDG uptake was low, moderate, and high in 64, 31, and 18 screenees, respectively. Gastritis was mild, moderate, and severe in 59, 44, and 10 screenees, respectively. A significant relation was observed between the degree of FDG uptake and the degree of gastritis (p＜0.0001). High FDG uptake was observed significantly more often in the upper half of the stomach than in the lower half (p＜0.0001). Similarly, gastritis was observed significantly more often in the upper half of the stomach (p=0.005). A significant relation was observed between the degree of FDG uptake and the severity of gastritis in both the upper (p＜0.0001) and lower (p=0.01) portions. In conclusion, the significant relation we found between the degree of FDG uptake and the severity of gastritis suggests that gastritis is a major cause of diffuse FDG uptake in the stomach.

Development and characterization of a model of liver metastasis using human colon cancer HCT-116 cells.

In order to develop a model of liver metastasis of human gastrointestinal cancer cells, we examined the potential of 10 human colon and stomach cancer cell lines (HT-29, WiDr, HCT-116, HCT-15, HCC-2998, MKN7, MKN28, MKN45, MKN74 and St-4) to form liver metastases in nude mice. Among the cell lines, HCT-116 cells consistently formed gross liver metastases when injected into the spleens of nude mice. In contrast, other human colon and stomach cancer cells produced little or no liver metastasis. In order to analyze the high metastatic potential of HCT-116 cells, the adhesion potential was compared between HCT-116 cells and the other colon cancer cell lines. HCT-116 cells showed more efficient adhesion to fibronectin (FN) than other cells. Furthermore, FN enhanced haptotaxis of HCT-116 cells, but not of other colon cancer cells. The high adhesion potential to FN and enhanced haptotaxis may contribute, at least in part, to the high metastatic potential of HCT-116. To assess the value of this newly developed model of liver metastasis, we compared the ability of four anticancer drugs (fluorouracil, doxifluridine, paclitaxel and irinotecan) to inhibit the formation of liver metastases. Paclitaxel and irinotecan showed strong inhibition of liver metastasis but fluorouracil and doxifluridine showed only slight inhibition. Therefore, this model of metastasis may be useful for screening anti-liver metastatic reagents. These results indicate that the HCT-116 liver-metastasis model should be useful for analyzing the molecular mechanism of liver metastasis and for evaluating new anti-liver metastatic drugs.

A case of the primary small intestinal cancer which performed operation under laparoscopy after ileus decompression.

The patient was a 66-year-old man with repeated episodes of abdominal pain resulting in a diagnosis of ileus, and he was admitted to this hospital. During hospitalization, the pain symptoms improved after the insertion of an ileus tube, but there was a recurrence of ileus after the patient was started on a liquid diet. An adhesive intestinal obstruction was thus suspected, and laparoscopy was performed. A diagnosis of small intestinal carcinoma was made based on the intraoperative findings. A partial resection of the small bowel and a regional lymphadenectomy were performed through a minor laparotomy. The incidence of primary small intestinal cancer has been relatively rare, and it is difficult to differentiate the disease in most cases. A laparoscopy is considered useful to diagnose and treat ileus after decompression of the intestinal tract, and this article describes the case with some discussion.

Esophagogastrostomy before proximal gastrectomy in patients with early gastric cancers in the upper third of the stomach.

OBJECTIVE: This study was designed to assess the outcome of esophagogastrostomy before proximal gastrectomy in patients with early gastric cancers in the upper third of the stomach. METHODS: From 1997 through 2004, we studied 10 consecutive patients. A stapler was introduced into the stomach, and an esophagogastrostomy was performed before proximal gastrectomy. Hill's posterior gastropexy and Dor's anterior fundic wrap were performed to prevent reflux esophagitis. RESULTS: The operation time was 171 ± 44 minutes, and the intraoperative bleeding volume was 294 ± 228 mL. There was no anastomotic leakage. Anastomotic stenosis, occurring in 40% of the patients, required endoscopic balloon dilatation. Symptoms of reflux esophagitis, occurring in 40% of the patients, resolved within 2 years after operation. As compared with the preoperative value, body mass index was significantly decreased 1 and 2 years after operation, but was similar at 3 to 5 years. The percent decrease in body weight after operation fluctuated between 6% and 8% between 2 and 5 years. Postoperative weight loss was thus mild. CONCLUSIONS: Esophagogastrostomy before proximal gastrectomy may be less invasive, simpler, and produce better outcomes than conventional procedures for the surgical treatment of early gastric cancer in the upper third of the stomach.

Laparoscopic treatment of intestinal intussusception in Peutz-Jeghers syndrome: case report and review of literature.

A 47-year-old woman presented with an abdominal mass and nausea. Abdominal ultrasound and computed tomography (CT) showed a sausage-shaped mass with invagination. One polyp that appeared to exceed 3 cm was found in the sigmoid colon. Laparoscopy confirmed an intussusception mass, and the intussusception was dissected by hand-assisted laparoscopy (HALS). The sigmoid colon was also mobilized to the site of the small incision and resected. Generally, we believe enterectomy including polyps should be avoided as much as possible in Peutz-Jeghers syndrome (PJS) because poly-surgery may lead to short bowel syndrome. In addition, PJS patients often undergo multiple surgery, and therefore dense intra-abdominal adhesions are seen at subsequent laparotomy, which makes surgery increasingly difficult with repeated operations. Laparoscopic-assisted surgery seems beneficial, as in the present case.

A case report of advanced thoracic esophageal cancer with severe malignant stricture.

We experienced one case with locally advanced esophageal cancer that he gained a good result by the multidisciplinary treatment including the operation followed by chemoradiation. The case was a 74-year old man with the middle thoracic esophageal cancer accompanied by severe malignant stricture. He couldn't take any water, and his general condition was poor, because he lost 5 kg of his weight. By the clinical examinations, his cancer had no apparent invasion to adjacent organ. So, we planned the operation gone ahead the chemoradiation for him to take water and meals earlier, and to prevent pneumonia. The esophagectomy through right-thoracotomy was done, and the pathological findings were type 3, well differentiated squamous cell carcinoma, pT3 N0, pStageII. Two months later after the operation, he took the chemoradiotherapy. 50 gray radiation therapy was done with chemotherapy including Cisplatin (10 mg/a time/week) and Tegafur (200 mg/day). About one and half a year after the operation, he sends good daily life with no recurrence. Recently, chemoradiotherapy is the first choice of the treatment for the locally advanced esophageal cancer. But in cases without apparent invasion to adjacent organ, it might be advisable that the operation goes ahead the chemoradiotherapy in the multidisciplinary treatment.

Estimation of the time of pulmonary metastasis in colorectal cancer patients with isolated synchronous liver metastasis.

OBJECTIVE: The aim of this study was to estimate the time when pulmonary metastases began to grow in colorectal cancer (CRC) patients with isolated synchronous liver metastasis based on the tumor doubling time (DT). METHODS: We examined 23 pulmonary metastases in 14 patients detected after resection of liver metastases from CRC (group 1) and 19 pulmonary metastases in eight patients detected after initiation of hepatic arterial infusion chemotherapy for synchronous unresectable liver metastases (group 2). The regression line was determined from the chest X-ray films, and the DT was calculated. RESULTS: We estimated the DTs of pulmonary metastases as 65.0 +/- 28.9 and 76.2 +/- 23.0 days in groups 1 and 2, respectively, and the time when pulmonary metastases began to grow as 16-1418 and 112-1464 days before the resection of liver metastases for 19 lesions in 12 out of 14 patients of group 1 and before resection of primary CRC in group 2, respectively. CONCLUSION: It appears that in some CRC patients in whom the metastatic site is considered to be limited to the liver at diagnosis, occult pulmonary metastasis has already taken place.

A case of primary small intestinal cancer diagnosed by laparoscopy.

The patient was a 61-year-old female who developed ileus. Physical findings showed abdominal distension but peritoneal irritation signs were not observed. After the conservative treatment by the ileus tube, encircling stenosis was observed in the jejunum at about 50 cm on the anal side from the Treitz ligament on contrast radiography of the small intestine through the ileus tube. Tumor markers were normal except for mild elevation of IL2-R (609 U/ml). After confirming sufficient bowel decompression and the absence of other lesions, surgery was performed based on a preoperative diagnosis of small intestinal tumor including adhesive ileus, GIST, or malignant lymphoma. First, under the laparoscopic observation, the lesion was resected and definitive diagnosis was established as primary moderately to poorly differentiated adenocarcinoma of the small intestine by rapid intraoperative pathological diagnosis. Then, extensive jejunal resection involving sufficient lymph node dissection was performed as open surgery. Radical surgery was successfully performed.