Endoscopy-assisted anastomosis: a modified technique for laparoscopic side-to-side esophagojejunostomy following a total gastrectomy.

INTRODUCTION: Esophagojejunostomy with a circular stapling device is sometimes difficult to perform in a laparoscopic setting. On the other hand, a side-to-side anastomosis with a linear stapling device is technically challenging. METHODS: Between June 2002 and March 2008, 10 consecutive patients underwent a laparoscopy-assisted total gastrectomy using a side-to-side anastomosis technique. Of these patients, four underwent a laparoscopy-assisted total gastrectomy with a modified anastomosis technique. A small wound was created on the antimesenteric side of the jejunum 5 cm distal to the resected portion and then in the lower esophagus. A peroral endoscope was advanced to the hole, and the cartridge fork was introduced into the lower esophagus under endoscopic guidance. The device (45 mm, blue) was fired to create an antiperistaltic side-to-side anastomosis. The common entry hole was closed by transecting the jejunum and the esophagus with another linear stapler and by using an endoscope as a stent. RESULTS: Four patients underwent the modified procedure and did not require an open procedure. One patient developed a pancreatic fistula, which was treated conservatively. The average operative time, reconstruction time and blood loss were 483 ± 133 minutes, 139 ± 31 minutes, and 199 ± 121 mL, respectively. An introduction of the stapler into the lower esophagus and a closure of the common entry hole were performed safely without any stress. CONCLUSION: Although several techniques must be compared to determine the ideal procedure for laparoscopic esophagojejunostomy, the modified side-to-side anastomosis technique may be useful in clinical settings.

Nutritional status of people living in Dzong village, in the northern mountainous area of Nepal.

A nutritional survey was carried out among residents (39 males and 46 females) of Dzong village in the northern area of the Gandaki region of Nepal. The results were compared with our previous findings. The mean body mass index value was under 21 for both sexes, but the mean percentage of body fat of females (17-19 years old, 25.8 +/- 9.4%; 20-29 years old, 31.0 +/- 8.4%) was higher than that of males (17-19 years old, 12.0 +/- 1.0%; 50-59 years old, 24.4 +/- 7.6%). Most serum nutritional markers for both sexes were generally at normal levels although the iron levels were lower and packed red cell volume levels were higher than normal. As determined by results of the 24-hr dietary recall survey, the main food groups consumed by both sexes were cereals, potatoes, pulses, meats and vegetables. The mean daily intake of nutrients was similar for both sexes, with a few exceptions. The relatively high serum TG levels of the subjects may have been due to the high consumption of carbohydrate-laden cereals. The amounts of food consumed were not adequate, resulting in a latent and chronic deficiency of nutrients, especially calcium and iron. These results suggest that improvements in the nutritional status of this group of people are necessary.

Conceptual equivalence and health-related quality of life: an exploratory study in Japanese and Dutch cancer patients.

Research into the equivalence of Western and Japanese conceptualizations of health-related quality of life (HR-QOL) is scarce. We used the Western (European Organization for Research and Treatment of Cancer, EORTC-QLQ-C30) and the Japanese (HRQoL-20) questionnaire in order to analyze the conceptual similarity of HR-QOL factors, and the associations between specific symptom items with overall HR-QOL in Japanese (n=265) and Dutch (n=174) patients with various types of cancer. Both populations completed both instruments. In both patient groups, the overall health scale of the EORTC-QLQ-C30 correlated highly (r=0.59; p<0.001) with the HRQOL-20 composite average score, indicating substantial conceptual comparability. Relationships between all EORTC-QLQ-C30 symptom items with HR-QOL were examined by ranking their correlations with the two overall measures of HR-QOL. Comparable patterns in the Japanese and Dutch samples were observed. The results suggest a considerable conceptual equivalence of HR-QOL in Japanese and Dutch cancer patients, and indicate a satisfactory structural and cross-cultural equivalence for the EORTC-QLQ-C30 with regard to items measuring functioning and specific symptoms. Longitudinal studies are needed to examine the impact of specific symptoms on general quality of life.

Clinicopathological study of cholelithiasis following gastric cancer surgery.

The purpose of this study was to compare liver function tests preoperatively and postoperatively in 2 cohorts of patients, those that developed gallstones after gastrectomy for cancer and those that did not develop gallstones. The cohorts were taken from 698 consecutive patients who underwent curative gastrectomy for gastric cancer between April 1980 and March 1995. In comparison with 698 patients, the gallstone group was characterized by the findings that the incidence of cholelithiasis was significantly higher in totally-gastrectomized patients and patients with upper stomach cancer. Comparison of the perioperative status revealed a significantly higher rate of complications in the gallstone patients. Analysis of the changes in liver function showed significantly higher values of glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, and alkaline phosphatase at time points of 1 and 3 months after surgery in the gallstone patients. The results suggest that the postoperative development of liver dysfunction and complications is associated with the formation of gallstones.

Helicobacter pylori infection in two areas in Japan with different risks for gastric cancer.

BACKGROUND: We evaluated the relationship between Helicobacter pylori and various factors associated with gastric cancer in two areas in Japan with different risks for mortality due to gastric cancer. METHODS: A total of 250 sera from Niigata and 209 from Okinawa were used. H. pylori antibody and CagA antibody were measured by antigen-specific ELISAs. Serum gastrin and pepsinogen levels were determined by RIA. RESULTS: Although there was no significant difference in H. pylori prevalence among the persons in Niigata (50%) and Okinawa (42%), CagA prevalence in these populations was significantly different, at 41% and 26%, respectively (OR = 1.98, 95%CI: 1.33-2.95, P < 0.01). Serum gastrin levels in Niigata were significantly lower than those in Okinawa in H. pylori-negative persons (P < 0.01). The serum pepsinogen I/II ratio in Niigata was significantly lower than that in Okinawa in H. pylori positive persons (P < 0.01), whereas there was no significant difference in H. pylori-negative persons. Among those positive for H. pylori, serum pepsinogen I/II ratio in Niigata was significantly lower than that in Okinawa in CagA-negative persons (P < 0.01), whereas no significant difference was observed in CagA-positive persons. CONCLUSIONS: These results suggest that the difference in the mortality ratio of gastric cancer between Niigata and Okinawa is mainly associated with the difference between areas in the prevalence of cagA-positive strains rather than that of H. pylori itself.

Focus on the histologic diversity in primary and lymph node lesions and the outcome of gastric cancer.

According to the Japanese Classification of Gastric Carcinoma, one predominant type should be selected to represent the histology of the carcinoma. The authors investigated the relationship among the histologic variables of primary lesions, metastatic lesions and the outcome of patients. A total of 155 patients with node-positive gastric carcinoma were examined. According to the histologic diversity, histologic grades were assigned from 1 to 4 regardless of the predominant histologic type. A larger number of histologic types composing not the primary lesions, but metastatic lymph nodes, were associated with an increasing frequency of advanced stage tumors. On the prognosis by number of histologic types composing the primary tumor and the metastatic lymph nodes, there were significant differences except between the histologic type-2 and histologic type-3 groups in the only metastatic lymph nodes. In conclusion, patients with a greater number of histologic types composing lymph node metastases had poorer prognosis than with a small number of histologic types. Histologic diversity within metastatic lymph node was thought to be important for determining the prognosis of patients with gastric cancer.

Genetic polymorphisms of cytochrome P450 1A1 and risk of gallbladder cancer.

The relation between cytochrome P4501A1 (CYP1A1) gene polymorphisms and the risk of gallbladder cancer was examined. To clarify individual differences in susceptibility to gallbladder carcinogenesis, we investigated the frequency of the Mspl and Ile-Val polymorphisms of the CYP1A1 gene, in 52 patients with gallbladder cancer (32 females, 20 males) and 104 healthy controls (64 females, 40 males). We then examined the relationship between the CYP1A1 polymorphisms and the development of gallbladder cancer in members of both sexes. A statistical difference in the frequencies of the MspI and Ile-Val polymorphisms or their alleles (ml, m2 and Ile, Val) was not observed in the male patients and controls. Among females, however, the frequencies of genotypes C and Ile/Val were significantly higher (p < 0.05) in the patients than in their controls. Moreover, the frequency of the hetero genotype Ile/Val was statistically higher (p < 0.05) in the female patients than in the male patients. This study demonstrated a significant over-representation of genotypes C and Ile/Val in female patients with gallbladder cancer. Females with genotypes C and/or Ile/Val may have a high genetic susceptibility to the development of gallbladder cancer.

[Awareness of the health and defecation tendencies among college students by location of domicile].

In order to compare the food habits and defecation tendencies by region, a questionnaire survey was conducted of 1722 college women (18-20 years of age) living in Sapporo (146), Sendai (183), Osaka (1214), and Kumamoto (179). (1) When questioned about food habits, less than 58.5% of the respondents in the four groups considered their food intake to be sufficient to maintain their health. In regard to knowledge about their food intake requirements, the positive response was the highest in Sendai (85.8%), followed by Kumamoto (58.2%) and Osaka (50.9%) with the lowest in Sapporo (41.1%) (p < 0.01, among the four groups). (2) The students in Sendai, Osaka, Kumamoto and Sapporo, 96.2%, 93.5%, 92.9% and 92.5%, respectively, considered that constipation could affect their health (p < 0.05, among four groups). The percentage of those with regular bowel movements every day, tended to decrease in the order of Osaka (22.2%), Sapporo (21.2%) and Sendai (20.8%), with the lowest in Kumamoto (12.3%). Bowel movements of less than three times a week were reported by 24.7% in Sapporo, 24.0% in Sendai, 23.2% in Osaka and 22.3% in Kumamoto (p < 0.01, among the four groups). (3) Of those who defecated every day, in terms of time of day, the percentage was high between waking and after breakfast, with the highest percentage in Kumamoto (72.8%) and the lowest in Sapporo (61.2%) (p < 0.05, among the four groups). For subjects that responded that they should have a bowel movement every day, the highest percentage was in Osaka (91.0%) and the lowest was in Sapporo (83.9%) (p < 0.05, among the four groups).

Preliminary study for sentinel lymph node identification with Tc-99m tin colloid in patients with esophageal or gastric cancer.

The purpose of this study is to determine whether a lymph node identified with high radioisotope (RI) activity is a sentinel node. We studied 26 patients with either esophageal or gastric cancer whose preoperative imaging studies showed no lymph node metastasis. Before surgery, Tc-99m tin colloid was injected via endoscopy into the submucosa. In lymph nodes dissected at surgery, RI activity was measured by a scintillation counter, and metastatic status was examined by hematoxylin-eosin staining. The number of dissected nodes was 45 +/- 15 (mean +/- SD) per patient, and the number of nodes with high RI activity was 4 +/- 1. Nodal metastasis occurred in 11 of 26 patients. In 9 of these 11 patients, metastatic foci were found in one or more nodes with high RI activity. In one of the 2 remaining patients, endoscopic clipping was applied just above the injection sites, and in the other patient, the tumor invasion was beyond the muscle layer. For further analysis, the case with clipping was excluded, and only those in which the tumor invasion was confined within the muscle layer were evaluated. Six of 18 patients in this analysis showed nodal metastasis. Each of the 6 patients had at least one node that showed high RI activity and that was positive for metastasis. We conclude that when tumor invasion remains within the muscle layer, lymph nodes with high RI activity can be regarded as sentinel nodes.

Reprocessing of gastrointestinal endoscopic accessories.

In this paper, the minimal standards for the disinfection of endoscopes and endoscopic accessories, as defined by the OMED's Minimal Standards for Disinfection, are described. Given the difficulties of disinfecting reusable accessories, disposable accessories are desirable and marketed by many companies. However, they are less economical than the reusable accessories available. Presently, both disposable and reusable forceps are marketed and those that are to be reused must be disinfected according to the Minimal Standards for Disinfection. This paper will discuss the factors to consider in choosing single-use or reusable accessories, such as economy, reliability of disinfection and durability of function. The one-time biopsy cost of reusable and disposable accessories that can be satisfactorily disinfected will also be compared. This paper concludes that the accessories used for endoscopic retrograde cholangiopancreatography are less reliably disinfected, less expensive and less durable compared with biopsy forceps.

Correlation between erythropoietin and lactate in humans during altitude exposure.

The plasma concentrations of both immunoreactive erythropoietin (EPO) and lactate were determined in four healthy untrained subjects at sea level and on the 2nd or 3rd day at altitudes (1,300 and 3,500 m). The mean plasma EPO (18.8 +/- 1.6 mU/ml at sea level) increased significantly on the 3rd day at 1,300 m (25.5 +/- 2.0 mU/ml, p < 0. 05) and showed an almost three-fold increase on the 2nd day at 3,500 m (53.5 +/- 3.7 mU/ml, p < 0.001). Likewise, the mean plasma lactate at 3,500 m (3.98 +/- 0.27 mmol/l) was 3.6 times as high as that at sea level (1.11 +/- 0.05 mmol/l) (p < 0.001). The plasma EPO concentrations were found to correlate well with the lactate concentrations at sea level and altitudes (r = 0.86, p < 0.01). These results are consistent with the well-known EPO/lactate response to altitudes and suggest that the circulating EPO concentration as well as blood lactate concentration can be used as an index of anaerobic condition.

Geographical variations in the concentration of biliary free fatty acids with anti-mutagenic action.

The concentrations and compositions of free fatty acids (FFAs) in human bile, especially of inhibitory free fatty acids (IFFAs), were analyzed in terms of anti-mutagenic effects in relation to the mutagenic activity of bile. Bile samples were collected from patients with cholelithiasis residing in either Niigata or Kochi prefectures of Japan, regions characterized as the highest and lowest risk areas for gallbladder cancer (GBC), respectively. Biliary FFAs and IFFAs were analyzed by high-performance liquid chromatography and mutagenicity was examined in by the Ames test (TA98+S9mix) after blue rayon treatment. There was a tendency for higher biliary FFA and IFFA concentrations in the Kochi subjects, but the proportion of IFFA to the total FFA concentration did not differ between the two areas. There was an inverse correlation between the concentrations of IFFAs and the numbers of revertant colonies in both Niigata and Kochi subjects. However, at a dose of 591 micromol/l, (calculated based on the average amount of IFFAs absorbed in blue rayon) IFFAs did not exhibit anti-mutagenic actions in the blue rayon extracts. Within this range, more positive samples were seen in Niigata than in Kochi, suggesting the presence of more active mutagen(s) in Niigata samples.

Small mucosal carcinoma of the stomach with para-aortic lymph node metastasis: a case report and review of the literature.

A 38-year-old woman presented with a mucosal gastric carcinoma measuring 0.7 x 0.5 cm and para-aortic lymph node metastasis. Radiographic and endoscopic studies showed a small depressed lesion on the anterior border of the gastric angle, which was classified as a type II c + III lesion. Histological examination of the biopsy specimen revealed a signet-ring cell carcinoma. Distal gastrectomy with wide lymph node excision was performed. Detailed study of the resected specimen revealed that the tumour was limited to the mucosa, but metastasized to both the perigastric and para-aortic lymph nodes. The patient received adjuvant immunochemotherapy postoperatively. However, multiple bone metastases developed at 3 years and she died 4 years after the operation.

A case of gastrointestinal stromal tumor of the stomach.

In a 55-year-old man, a tumor about 3 cm in diameter was detected in the upper abdomen by abdominal ultrasound screening during follow-up of chronic hepatitis C discovered in 1990. There were no symptoms and no abnormalities on physical examination. Tests for tumor markers were negative. By barium meal and gastroscopy, submucosal tumor was found on the lesser curvature of the stomach, with bridging fold in the absence of central ulceration. Biopsy revealed no tumor tissue. Under the diagnosis of submucosal tumor of the stomach, either a leiomyoma or leiomyosarcoma, partial resection of stomach was performed. Direct invasion of the surrounding organs, lymph node metastasis or distant metastasis was not observed grossly in the operation. Histologic examination of the resected specimen revealed proliferation of spindle cells and oval cells in an interlacing pattern. Immunohistochemistry for CD34, vimentin and c-kit protein was strongly positive, while smooth muscle actin, S-100 protein, desmin and p53 protein were negative. The proliferating cell nuclear antigen index was about 50%, while the MIB-1 index was < or = 1%. From these findings, this tumor was diagnosed as a gastrointestinal stromal tumor of the uncommitted type.

5-fluorouracil continuous infusion combined with cisplatin for advanced pancreatic cancer: a Japanese Cooperative Study.

BACKGROUND/AIMS: The prognosis of patients with advanced pancreatic cancer is extremely poor. To improve their prognosis, providing effective chemotherapy is necessary. The aim of this study was to evaluate the anti-tumor activity and toxicity of combined chemotherapy (FP therapy) using 5-fluorouracil and cisplatin in Japanese chemo-naive patients with advanced pancreatic cancer. METHODOLOGY: Thirty-seven previously untreated patients with histologically proven pancreatic adenocarcinoma were treated with FP therapy. 5-fluorouracil was administered at 500 mg/m2/day by continuous intravenous infusion for 5 days and cisplatin was administered at 80 mg/m2 intravenously on the 1st day. Therapy was repeated every 4 weeks until there was evidence of disease progression or unacceptable toxicity. RESULTS: Three patients achieved partial responses, whereas none exhibited a complete response. The overall response rate was 8% (95% confidence interval, 2-22%) and the response durations were 6, 9 and 12 months, respectively. The median survival time of patients was 5 months. Toxicities were generally mild and acceptable, although nausea/vomiting was the most commonly observed toxicity. CONCLUSIONS: FP therapy on this schedule had limited anti-tumor activity for pancreatic cancer, indicating that, practically, it should not be performed in Japanese patients with advanced pancreatic cancer.

Modification of mutagenic activities of pro-mutagens by glyco-ursodeoxycholic acid in the Ames assay.

Mutagenicity, co-mutagenicity and anti-mutagenicity of glycoursodeoxycholic acid (GUDCA) were examined by the Ames assay using Salmonella typhimurium strain TA98 with S9. As pro-mutagens, 2-aminoanthracene (2AA), Benzo[a]pyrene (BaP), 3-amino-1-dimethyl-5H-pyrido[4, 3-b]indole (Trp-P-2), 2-amino-3-methylimidazo[4, 5-f]quinoline (IQ) and 2-amino-3, 4-dimethylimidazo[4, 5-f]quinoline (MeIQ) were used. In addition to these pro-mutagens, blue-chitin extracts of human gallbladder bile (BCE) collected from the cholecystectomized patients with cholelithiasis were used in order to investigate the role of GUDCA on mutagen(s) actually existing in human bile. It was found that GUDCA did not show mutagenicity in this test system. Concerning the modification of mutagenic activities of pro-mutagens, GUDCA showed the different directions. GUDCA acted as co-mutagen, since it enhanced the mutagenic activities of 2AA and BaP. But, acted as anti-mutagen, since it suppressed the activities of Trp-P-2, IQ and MeIQ, all of which were classified as heterocyclic amines. GUDCA also suppressed the mutagen(s) in human bile. Because of the use of blue-chitin absorbed method for testing bile mutagenicity, the chemicals involved were considered to be heterocyclic amines and other polycyclic compounds. In these we suspect the bile mutagens are heterocyclic amines. Further examination should be directed towards the investigation into the mechanism of anti-mutagenic effects of GUDCA on mutagen(s) actually existing in human bile.