[Two cases of esophageal variceal rupture associated with chemotherapy for liver metastasis of breast cancer].

A morphological change resembling liver cirrhosis called pseudocirrhosis may be observed following chemotherapy for liver metastasis of breast cancer. Pseudocirrhosis is hypothesized to be caused by retraction of the hepatic capsule along with tumor shrinkage and subsequent scar formation around the metastatic lesion, as a response to the infiltrating tumor or chemotherapy-induced hepatic injury. The progression of cirrhotic changes may result in portal hypertension and esophageal varices. We managed two cases of esophageal variceal rupture during chemotherapy for breast cancer with liver metastasis. Hemostasis was successfully achieved by the endoscopic variceal ligation technique in both cases. We conclude that clinicians should be aware of the risk of pseudocirrhosis during chemotherapy for liver metastasis, and a periodic endoscopic follow-up is recommended along with appropriate management of esophageal varices.

Meta-analysis of the results of randomized controlled trials that compared laparoscopic and open surgery for acute appendicitis.

PURPOSE: We conducted a meta-analysis to evaluate and compare the outcomes of laparoscopic and open surgery for the treatment of patients with acute appendicitis. METHODS: We searched MEDLINE, EMBASE, Science Citation Index, and the Cochrane Controlled Trial Register for relevant papers published between January 1990 and February 2012. We analyzed 22 outcomes of laparoscopic and open surgery for acute appendicitis. RESULTS: We identified 39 papers reporting results from randomized controlled trials that compared laparoscopic surgery with open surgery for acute appendicitis. Our meta-analysis included 5,896 patients with acute appendicitis; 2,847 had undergone laparoscopic surgery, and 3,049 had undergone open surgery. Compared with open surgery, laparoscopic surgery was associated with longer operative time (by 13.12 min). However, compared with open surgery, laparoscopic surgery for acute appendicitis was associated with earlier resumption of liquid and solid intake; shorter duration of postoperative hospital stay; a reduction in dose numbers of parenteral and oral analgesics; earlier return to normal activity, work, and normal life; decreased occurrence of wound infection; a better cosmesis; and similar hospital charges. CONCLUSIONS: Laparoscopic surgery may now be the standard treatment for acute appendicitis.

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.

A meta-analysis of the short- and long-term results of randomized controlled trials that compared laparoscopy-assisted and conventional open surgery for colorectal cancer.

PURPOSE: We conducted a meta-analysis to evaluate and compare the short- and long-term results of laparoscopic colorectal surgery (LCRS) and conventional open surgery (OCRS) for colorectal cancer (CRC). METHODS: We searched relevant papers published between January 1990 and May 2011. We analyzed the outcomes of each type of surgery over the short- and long-term periods. RESULTS: In the short-term period, we found no significant differences in overall perioperative complications and anastomotic leakage between LCRS and OCRS groups. We found no significant differences in overall, distant, local and wound-site recurrence, overall mortality, 3 and 5 year disease-free survival rate, and cancer-related mortality between the 2 groups. CONCLUSIONS: LCRS has the benefits of reducing intraoperative blood loss, earlier resumption of oral intake, and shorter duration of hospital stay in the short-term. The long-term outcomes of LCRS seem to be similar to those of OCRS.

Comparison of the outcomes between anatomical resection and limited resection for single hepatocellular carcinomas no larger than 5 cm in diameter: a single-center study.

BACKGROUND/PURPOSE: Liver resection is a widely preferred treatment modality for hepatocellular carcinomas (HCCs). This study aimed to compare the survival impact of anatomical resection with that of limited resection, in patients with single HCCs no larger than 5 cm in diameter. METHODS: A cohort study was carried out on 209 consecutive patients who underwent hepatic resection for a single HCC no larger than 5 cm in diameter between January 1994 and March 2007 at Osaka City General Hospital. RESULTS: The cumulative 5-year overall survival and disease-free survival rates in the anatomical resection group (n = 111) were 71 and 40%, respectively, both of which were significantly better than the 48 and 25% seen in the limited resection group (n = 98) (P = 0.0043 and P = 0.0232, respectively). Better effects of the anatomical resection on both overall and disease-free survival were seen in patients having HCC larger than 2 cm in diameter and in patients with moderately or poorly differentiated HCC. But no significant difference in either overall or disease-free survival was seen between the groups in patients with a HCC 2 cm or less in diameter or in the patients with well-differentiated HCC. Using Cox's regression model, anatomical resection was confirmed to be an independent favorable factor for both overall and disease-free survival. CONCLUSIONS: Anatomical resection is therefore recommended for histologically advanced single HCCs ranging from 2 to 5 cm in diameter.

Efficacy and toxicity of fluorouracil, leucovorin plus oxaliplatin (FOLFOX4 and modified FOLFOX6) followed by fluorouracil, leucovorin plus irinotecan(FOLFIRI)for advanced or metastatic colorectal cancer--case studies.

AIM: In this study, we investigated the efficacy and toxicity of fluorouracil(FU)+Leucovorin(LV)with oxaliplatin (FOLFOX)and irinotecan(FOLFIRI)for patients with advanced or metastatic colorectal cancer. METHODS: Eleven patients with advanced or metastatic colorectal cancer underwent chemotherapy, such as FOLFOX4, mFOLFOX6, and FOLFIRI. Four and 7 patients underwent FOLFOX4 and mFOLFOX6 as a first-line therapy, respectively. Five patients underwent FOLFIRI as a second-line therapy. RESULTS: The response rate(RR)for FOLFOX4 and mFOLFOX6 as a firstline therapy was 0%(0 of 4 patients)and 71%(5 of 7 patients), respectively. The RR for FOLFIRI as a second-line therapy was 40%(2 of 5 patients). The survival time of the eight patients experiencing CR, PR or SD in the firstline FOLFOX4/mFOLFOX6 or the second-line FOLFIRI is 7 to 27 months. That of the three patients not showing CR, PR or SD is 4 to 8 months. The former is significantly longer than the latter(p=0.0023). Toxicities were paresthesia, neutropenia, thrombocytopenia and general fatigue in FOLFOX4, paresthesia, neutropenia, thrombocytopenia, diarrhea and anaphylaxis in mFOLFOX6, while those were neutropenia, thrombocytopenia, stomatitis and general fatigue in the second-line FOLFIRI. CONCLUSION: For advanced or metastatic colorectal cancer, FOLFOX4/mFOLFOX6 followed by FOLFIRI may be effective and comparatively safe treatments.

[A case of advanced gastric cancer with pulmonary carcinomatous lymphangitis and paraaortic lymph node metastases responding to combination chemotherapy of S-1 and irinotecan(CPT-11)].

A 70-year-old woman with pulmonary carcinomatous lymphangitis and paraaortic lymph node metastases due to gastric cancer, was treated by combination chemotherapy of S-1 and irinotecan (CPT-11). After one course of the chemotherapy, pulmonary carcinomatous lymphangitis and paraaortic lymph node metastases were remarkably improved. Diet intake was improving and cancer pain remarkably declined. Because the origin of gastric cancer was not improved, total gastrectomy, distal pancreatectomy and splenectomy were performed. After surgery, relapse of pulmonary carcinomatous lymphangitis caused death of the patient. The combination chemotherapy of S-1 and CPT-11 was effective for pulmonary carcinomatous lymphangitis and paraaortic lymph nodes metastases due to gastric cancer. However, careful consideration is required since surgery is performed on a patient who had suffered pulmonary carcinomatous lymphangitis.

A case of solid neuroendocrine carcinoma of the breast in a 40-year-old woman.

We report a case of neuroendocrine carcinoma in a 40-year-old woman who presented with two lumps in her left breast. Mammography failed to reveal any lesions because she had so-called dense breasts, but ultrasonography showed 4 irregular hypoechoic masses. Magnetic resonance imaging also showed 4 homogeneous lobulated tumors with early contrast enhancement, suggesting malignancy. Core needle biopsy and subsequent immunohistochemical examination of the specimens was performed. Neuroendocrine carcinoma was diagnosed. The tumor cells were diffusely positive for chromogranin A and synaptophysin, and some were positive for CD56. We performed total mastectomy with sentinel lymph node biopsy, which showed no metastasis. Recurrence has not been detected at 36 months after surgery.

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

BACKGROUND: We attempted to elucidate the current status of endoscopic self-expanding metal stents for palliation of malignant gastroduodenal obstruction in comparison with surgical gastroenterostomy. METHODS: Original 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. RESULTS: The 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. CONCLUSIONS: Endoscopic 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.

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.

Meta-analysis of short-term outcomes after laparoscopy-assisted distal gastrectomy.

AIM: To elucidate the current status of laparoscopy-assisted distal gastrectomy (LADG) with regard to its short-term outcomes by comparing it with conventional open distal gastrectomy (CODG). METHODS: Original articles published from January 1991 to August 2006 were searched in the MEDLINE, EMBASE, and Cochrane Controlled Trials Register. Clinical appraisal and data extraction were conducted independently by 2 reviewers. A meta-analysis was performed using a random effects model. RESULTS: Outcomes of 1611 procedures from 4 randomized controlled trials and 12 retrospective studies were analyzed. Compared to CODG, LADG was a longer procedure (weighted mean difference [WMD] 54.3; 95% confidence interval [CI] 38.8 to 69.8; P < 0.001), but was associated with a lower associated morbidity (odds ratio [OR] 0.54; 95% CI 0.37 to 0.77; P < 0.001); this was most significant for postoperative ileus (OR 0.27; 95% CI 0.09 to 0.84; P = 0.02). There was no significant difference between the two groups in anastomotic, pulmonary, and wound complications and mortality. Duration from surgery to first passage of flatus was faster (WMD -0.68; 95% CI -0.85 to -0.50; P < 0.001) and the frequency of additional analgesic requirement (WMD -1.36; 95% CI -2.44 to -0.28; P = 0.01), and duration of hospital stay (WMD -5.51; 95% CI -7.61 to -3.42; P < 0.001) were significantly lower after LADG. However, a significantly higher number of lymph nodes were dissected by CODG (WMD -4.35; 95% CI -5.73 to -2.98; P < 0.001). CONCLUSION: LADG for early gastric cancer is associated with a lower morbidity, less pain, faster bowel function recovery, and shorter hospital stay.

Efficacy of multislice computed tomography for gastroenteric and hepatic surgeries.

AIM: To determine the efficacy of multislice CT for gastroenteric and hepatic surgery. METHODS: Dual-phase helical computed tomography was performed in 50 of 51 patients who underwent gastroenteric and hepatic surgeries. Twenty-eight, eighteen and four patients suffering from colorectal cancer, gastric cancer, and liver cancer respectively underwent colorectal surgery (laparoscopic surgery: 6 cases), gastrectomy, and hepatectomy. Three-dimensional computed tomography imaging of the inferior mesenteric artery, celiac artery and hepatic artery was performed. And in the follow-up examination of postoperative patients, multiplanar reconstruction image was made in case of need. RESULTS: Scans in 50 patients were technically satisfactory and included in the analysis. Depiction of major visceral arteries, which were important for surgery and other treatments, could be done in all patients. Preoperative visualization of the left colic artery and sigmoidal arteries, the celiac artery and its branches, and hepatic artery was very useful to lymph node dissection, the planning of a reservoir and hepatectomy. And multiplanar reconstruction image was helpful to diagnosis for the postoperative follow-up of patients. CONCLUSION: Three-dimensional volume rendering or multiplanar reconstruction imaging performed by multislice computed tomography was very useful for gastroenteric and hepatic surgeries.

Three-dimensional computed tomography in laparoscopic surgery for colorectal carcinoma.

AIM: To evaluate the usefulness of three-dimensional computed tomography (3DCT) in laparoscopic surgery for colorectal carcinoma. METHODS: Seventy-two patients with colorectal cancer who underwent curative operation at our hospital were enrolled in this study. They were classified into two groups by operative procedures. Sixteen patients underwent laparoscopic surgery, laparoscopic group (LG), while 56 patients underwent conventional open surgery, open group (OG). At our institution, contrast-enhanced CT is routinely performed as part of intra-abdominal screening and the 3D images of the major regional vessels are described. We have previously described about the preoperative visualization of the inferior mesenteric artery (IMA) by 3DCT. This time we newly acquired 3D images of the superior mesenteric artery (SMA)/superior mesenteric vein (SMV), ileocecal artery (ICA), middle colic artery (MCA), and inferior mesenteric vein (IMV). We have compared our two study groups with regard to five items, including clinical anastomotic leakage. We have discussed here the role of 3DCT in laparoscopic surgery for colorectal carcinoma. RESULTS: The mean length of the incision in LG was 4.625+/-0.89 cm, which was significantly shorter than that in OG (P<0.001). The association between ICA and SMV and SMA was described in the right-sided colectomy. The preoperative imaging of IMA and IMV was created in the rectosigmoidectomy. There was no significant difference in anastomotic leakage between the two groups, but no patients in LG experienced anastomotic leakage. CONCLUSION: Most of the patients are satisfied with the shorter incisional length following laparoscopic surgery. Preoperative visualization of the major regional vessels may be helpful for the secure treatment of the anastomosis in laparoscopic surgery for colorectal carcinoma.