Diagnosis of inguinal hernia by prone- vs. supine-position computed tomography.

PURPOSE: The aim of this study was to investigate the efficacy of prone-position computed tomography (CT) for detecting and classifying inguinal hernia relative to supine-position CT before laparoscopic inguinal hernia repair. METHODS: Seventy-nine patients who underwent laparoscopic transabdominal preperitoneal repair of inguinal hernia were enrolled in this prospective study. Patients diagnosed with inguinal hernia by physical examination underwent abdominal CT in the supine and prone positions for preoperative assessment. The anatomy of the right and left inguinal regions was confirmed during the surgery and compared with the preoperative CT findings. RESULTS: The 79 cases included 87 operated lesions and 71 non-operated contralateral inguinal sites. Of the 84 clinical hernias, inguinal hernia was detected significantly more frequently on prone-position CT images (84, 100%) than on supine-position CT images (55, 65.5%). In addition, the inguinal hernia type was determined with significantly greater accuracy on prone-position CT images (96.4%) than on supine-position CT images (58.3%). Twenty-two occult hernias were detected by laparoscopy. The detection rate and accuracy for determining the type of occult hernia were significantly greater when using prone-position CT images [19 of 22 lesions (86.4%) and 77.3%, respectively] than when using supine-position CT images [8 of 22 lesions (36.4%) and 27.3%, respectively]. CONCLUSIONS: Prone-position CT is adequate for detecting and classifying inguinal hernia and for evaluating occult hernia.

Complications after proximal gastrectomy with jejunal pouch interposition: report of a case.

We report a rare case of proximal gastrectomy complication as a result of a severe dilatation of a jejunal pouch interposed for reconstruction. A 44-year-old man who had early gastric cancer underwent proximal gastrectomy with a jejunal pouch interposition at our department. Fourteen months after the procedure, he began to complain of left hypochondrial fullness and reflux symptoms. He had difficulty eating and his quality of life (QOL) was markedly impaired. Barium meal revealed severe dilatation of the jejunal pouch. Decompression using a stomach tube and other measures only achieved temporary improvement. 4.5 years later, the dilated jejunal pouch was resected together with apyloroplasty and double tract reconstruction. Six months after this secondary surgery, the patient recorded no further complications. Food intake increased and QOL improved.

Study on endoscopic esophageal mucosal resection with ligating device. I--Clinical study.

BACKGROUND/AIMS: EEMRL (endoscopic esophageal mucosal resection with a ligating device) has become increasingly popular. In this article, we review 13 clinical cases of EEMRL. METHODOLOGY: Since 1993, we have performed EEMRL to treat 15 lesions in 13 patients. Twelve squamous cell carcinomas (mucosal cancer in 10 and submucosal cancer in 2) were included among the 15 lesions. RESULTS: EEMRL failed to achieve complete resection of the 2 submucosal lesions (3.0 and 2.8 cm in maximum diameter). However, esophageal lesions could be removed successfully when 2.5 cm or less in maximum diameter. The procedure was not associated with any complication. CONCLUSIONS: Our clinical study showed that this technique may be indicated for esophageal cancer with a maximum diameter < or = 2.5 cm and confined to the mucosa. EEMRL is a technically easy and minimally invasive therapy which could be useful for the treatment of early esophageal cancer.

Study on endoscopic esophageal mucosal resection with ligating device. II--Experimental study.

BACKGROUND/AIMS: This study reports on animal experiments regarding the safety of endoscopic esophageal mucosal resection with a ligating device (EEMRL), as well as the amount of mucosa which can be removed by this technique, the depth of resection and the feasibility of piecemeal resection. METHODOLOGY: Three experiments were performed in six mongrel dogs under general anesthesia. RESULTS: When EEMRL was done without submucosal injection of saline, resection reached the muscular layer and caused esophageal perforation. The average dimensions of the mucosal pieces resected using 8-, 10-, and 12-mm devices was 13 x 10 mm, 18 x 15 mm, and 22 x 18 mm, respectively. Resection reached the mid-plane of the submucosa and the depth was almost uniform. After piecemeal resection, there was no macroscopically visible mucosa at the resection site and each mucosal piece was resected along the mid-plane of the submucosa. CONCLUSIONS: The experimental study indicated that submucosal injection of saline is essential to prevent esophageal perforation. It also showed that EEMRL allows resection up to the mid-plane of the submucosa, that the 12-mm device allows en bloc resection of lesions < or = 15 mm in diameter and that EEMRL is suitable for piecemeal resection.

Effect of intratumoral OK-432 administration of thymidine phosphorylase expression in human gastric carcinoma.

It is known that thymidine phosphorylase (dThdPase) is increased in various types of malignant tumors and is induced by cytokines. In this study, we have investigated the effects of OK-432, which induces multiple cytokines, on dTHdPase expression and angiogenesis in human gastric carcinomas. We examined 25 patients who underwent gastrectomy for gastric carcinoma. OK-432 was directly injected in tumors in 16 (OK group) of 25 patients via endoscopy before operation and the other 9 patients were not treated (control group). The dThdPase activity in carcinoma tissues of the OK group was significantly higher than that of the control group (P < 0.05). The amounts of IL-1 alpha, IFN-alpha, and IFN-gamma in carcinomas in the OK group were significantly higher than in the controls (P < 0.05), and these were significantly correlated with the dThdPase activity. Intratumoral OK-432 administration enhances the expression of dThdPase in gastric carcinoma cells by inducing various cytokines.

[A case of esophageal cancer with excellent response to oral UFT treatment].

The patient was an 83-year-old Japanese male with the chief complaint of difficulty in swallowing. On Feb. 24, 1997, he was referred to our hospital under suspicion of esophageal cancer. X-P revealed an image of a protrusion at Im-Iu having a long diameter of 6 cm. Endoscopy revealed that the esophageal lumen was nearly completely obstructed due to the presence of an irregularly-shaped tumor. The pathological finding of biopsized specimen was a squamous cell carcinoma. Thus, this case was diagnosed as esophageal cancer, but surgery was deemed inappropriate due to the patient's advanced age. Accordingly, on March 12, treatment was started with oral administration of UFT-E granules (Tegafur, 450 mg/day). Initially, the patient was unable to ingest even liquids, but beginning around May the blockage of the esophagus disappeared. Endoscopic examination performed in June revealed that the tumor had shrunk to a about 1 cm in diameter. Although tumor tissue remained, the tumor was observed to have undergone further reduction in size at 6 months after the start of chemotherapy. Moreover, the patient gained weight. This is considered to be a very rare case of an excellent response of esophageal cancer to oral administration of only UFT agents.

Clinical evaluation of endoscopic injection sclerotherapy using n-butyl-2-cyanoacrylate for gastric variceal bleeding.

BACKGROUND: Emergency endoscopic injection sclerotherapy (EIS) has been applied to the initial treatment of gastric variceal bleeding and various methods have been attempted. METHODS: Emergency EIS was performed on 38 patients with gastric variceal bleeding using either the ethanolamine oleate (EO) method or n-butyl-2-cyanoacrylate (Histoacryl) method and the outcome was compared. RESULTS: Complete haemostasis was defined as continuous haemostasis lasting for 14 days or more. Complete haemostasis was achieved in 52.4% of patients in the EO method versus 100% of those treated with the Histoacryl method, a significant difference, suggesting that the Histoacryl method was superior for achieving haemostasis in an emergency. The cumulative non-bleeding rate was also significantly higher in patients treated with Histoacryl, indicating the durability of haemostasis. There were no serious complications in patients who received either method of sclerotherapy. Post-EIS surgery was required in 42.8% of patients treated with EO, while no surgery was required in those treated with Histoacryl, supporting the greater haemostatic effect of Histoacryl. Although there was no significant difference in the cumulative survival rates of patients treated by these two methods, death from haemorrhage was avoided by using Histoacryl. CONCLUSIONS: Based on these results, the Histoacryl method is thought to be the initial treatment of choice for gastric variceal bleeding, because it achieved superior haemostasis compared with EO and death by haemorrhage was avoided.

Alpha-fetoprotein producing Barrett's esophageal adenocarcinoma: a case report.

A 59-year-old man was admitted to our hospital with upper abdominal pain. His serum alpha-fetoprotein (AFP) level was very high, 1500 ng/ml. Upper gastrointestinal endoscopy revealed depressed lesion at 36 cm from the upper incisors, with columnar epithelium lining the esophagus circumferentially to the oral side of the lesion. Histological examination of biopsy specimens revealed a tubular adenocarcinoma as well as the presence of gastric columnar epithelium with intestinal metaplasia. Immunohistochemistry demonstrated AFP in the tumor cells. From these results, a diagnosis of AFP-producing esophageal adenocarcinoma occurring in Barrett's esophagus, a condition which is extremely rare in Japan, was established. Computed tomography (CT) showed multiple metastasis on the liver and wide-ranging lymph node metastasis. Chemotherapy was not effective and the patient died about 2 months after the start of treatment. The AFP-producing esophageal adenocarcinoma presented here had biological characteristics similar to those of AFP-producing gastric cancer.

[Studies on pulmonary and systemic hemodynamic changes after transjugular intrahepatic portosystemic shunt (TIPS)].

In 10 patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) at our institution, postoperative pulmonary and systemic hemodynamic changes were compared with those before the procedure. After TIPS, right atrial and pulmonary capillary wedge pressures, cardiac output, and cardiac index increased significantly, and there was a significant decrease in total peripheral resistance. Thus, systemic hemodynamic changes showed evidence of a more hyperdynamic circulation. In addition, right ventricular end-diastolic volume index was significantly increased and this increase was persistent, with maintained right heart strain. With respect to pulmonary hemodynamics, alveolar arterial oxygen difference and right-to-left shunt increased significantly, along with a significant decrease in arterio-venous oxygen content difference, which indicated impairment of pulmonary diffusing capacity. These findings suggest that preoperative evaluation of the cardiac reserve and pulmonary function is important before performing TIPS. After TIPS, patients should be followed carefully because postoperative heart failure or pulmonary edema may occur.

[Influence of intratumor administration of OK-432 on the tumor selectivity of 5'-DFUR].

The influence of intratumor administration of OK-432 on the tumor-selective antitumor effect of 5'-DFUR was studied in 49 patients with advanced gastric cancer. The patients were divided into 4 groups that received oral 5'-DFUR, intratumor OK-432, oral 5'-DFUR plus intratumor and intracutaneous OK-432, or no therapy before operation. Using surgical specimens, the PyNPase activity and 5-FU content were measured, and the localization of PyNPase was determined immunohistologically. The results were as follows: 1) 5'-DFUR therapy decreased intratumor PyNPase activity whereas administration of OK-432 increased it. 2) PyNPase activity was higher in cancer tissue than in normal tissue for all groups. 3) The 5-FU content of cancer tissue was higher in patients receiving OK-432 plus 5'-DFUR than in patients receiving 5'-DFUR alone. 4) In the resected tumors, PyNPase was mainly localized in the cancer cells of some patients and in the stromal cells of others. Thus, the localization of PyNPase showed two major patterns.

[A case of advanced esophageal cancer made resectable by preoperative combination therapy with 5-FU and CDDP].

The authors experienced a case of advanced esophageal cancer made resectable by combination therapy with 5-FU and CDDP as a neoadjuvant chemotherapy. The patient was a 69-year-old-man suffering from esophageal cancer of A3.N4 (+).Pl0.M0 at stage IV. At this case was diagnosed to be radically unresectable, this form of combination therapy was used. The patient showed PR after 2 courses and the operation could then be conducted. The intraoperative findings revealed fibrous fusion of tumor with the aorta, but no direct invasion. The metastatic lymph nodes were necrotized and reduced. It was evaluated as Grade 3 in accordance with the "Histologic criteria for the effects of anticancer chemotherapy." The postoperative course was favorable without recurrence. This therapy caused no adverse reactions and seems effective as a neoadjuvant chemotherapy for advanced esophageal cancer.

[Study on pyrimidine nucleoside phosphorylase (PyNPase) activity in resected tissues of patients with gastric cancer].

Pyrimidine nucleoside phosphorylase (PyNPase) activity was measured in gastric cancer tissue from 25 patients who underwent resections of gastric cancer. The relation between the activity and host and tumor factors in gastric cancer was studied, and the following results were obtained. 1. PyNPase activity was 128.3 +/- 99.5 in cancer tissue and 37.2 +/- 23.1 in non-cancer tissue. The level was significantly higher in cancer tissue (p < 0.0001). 2. With respect to host factors, the PyNPase activity tended to be high in patients in whom cell-mediated immune response was maintained. 3. With respect to tumor factors, the values tended to be high in patients who were positive for lymph vessel and venous invasion, and positive for lymph node metastasis. 5'-deoxy-5-fluorouridine(5'-DFUR) is an anticancer agent which manifests antitumor effects when it is transformed into 5-FU by PyNPase. When this agent is administered to gastric cancer patients, it can be expected to be more effective in the above types of patients because of its characteristics.

[Portal hemodynamic changes from TIPS--evaluation with pulse Doppler method].

Transjugular intrahepatic portosystemic shunt (TIPS) was applied in three patients with Child C liver cirrhosis. Portal venous pressure was reduced by an average of 10.7 mmHg, and results such as the disappearance of esophageal varices and reduction in ascites were obtained. The portal hemodynamics of these three patients was observed before and after TIPS using the pulse Doppler method. When portal hemodynamics in the main portal vein was examined before TIPS, it was found that the mean blood flow velocity had decreased, the blood flow volume was reduced and the cross-sectional area of the vein had increased. The congestion index was high and there was definite congestion of the portal venous system. After TIPS, the blood flow velocity and volume increased, the cross-sectional area of the vein was reduced and the congestion index was lower. Congestion of the portal venous system was improved in these three patients and the clinical efficacy of TIPS was proven by these results. If the stent can be detected sonographically, stent patency is easily confirmed with the pulse Doppler method which is usefull examination technique for follow-up of patients undergoing TIPS.

Clinical studies of type-I procollagen carboxyterminal peptide in serum of patients with gastric cancer: comparison with CEA and CA19-9.

The serum level of a newly developed monoclonal antibody against type-I procollagen carboxyterminal peptide (P-1-P) was determined in patients with gastric cancer. The location of P-1-P in gastric cancer tissue was also investigated. We found that: (1) The serum P-1-P level and the positivity rate in patients with gastric cancer were similar to those in patients with other malignant or benign GI diseases and healthy individuals. (2) In patients with gastric cancer, the P-1-P positivity rate was significantly lower than that of CEA or CA19-9. (3) In patients with gastric cancer, the P-1-P positivity rate increased as the disease stage advanced. (4) Among patients with gastric cancer, the P-1-P positivity rate was significantly higher in those with scirrhous type than in those with medullary or intermediate type. (5) P-1-P was detected in the cytoplasm of cancer cells. P-1-P staining was stronger in scirrhous type and histologically undifferentiated gastric cancer. These results show that P-1-P can serve as a good marker for scirrhous type gastric cancer. The production of collagen by cancer cells themselves seems to be involved in collagen production in scirrhous type gastric cancer.

[Clinical evaluation of tumor markers in patients with colorectal cancer].

In 117 patients with colorectal cancer, the serum levels of CEA, TPA, CA 19-9, IAP, and, AFP have been compared with the clinical findings. The combined assay of 5 tumor markers were found to be useful for the screening of colorectal cancer. Excluding the AFP, positive rate of the markers for colorectal cancer was higher than that for breast cancer (p less than 0.01) and similar to that for gastric cancer. The serum levels of TPA, CEA and CA 19-9 correlated with the histological progression. Thus, they may be an indicator of the degree of lymph node metastasis, liver metastasis, the histological depth, and also may be useful in evaluating the prognosis of patients with colorectal cancer.

[Clinical utility of tumor markers in gastric and colon cancer].

Serum TPA and CEA level were measured in patients with gastric or colon cancer during the course of surgical treatment, and those clinical utility was evaluated. Both markers level were shown to be highest in colon cancer, followed by gastric cancer, benign diseases, and healthy subjects. Late stage patients, especially inoperable patients or patients in recurrence showed significantly high TPA and CEA level compared to early stage patients. Both markers were considered to be useful not only postoperative following up for recurrence but also preoperative evaluation for resectability and prognosis and postoperative evaluation for the treatment itself.