Splenic abscess diagnosed following relapsing sterile peritonitis in a peritoneal dialysis patient: A case report with literature review.

Peritoneal dialysis (PD)-related peritonitis is sometimes complicated with other infections; however, few cases of splenic abscess have been reported. We present the case of a 64-year-old PD patient with complicated splenic abscesses diagnosed following relapsing sterile peritonitis. After PD induction, he presented with turbid peritoneal fluid and was diagnosed with PD-related peritonitis. A plain abdominal computed tomography (CT) did not reveal any intra-abdominal focus of infection. After empiric intravenous antibiotics, the peritoneal dialysate was initially cleared, with a decrease in dialysate white blood cells (WBC) to 20/µL. However, WBC and C-reactive protein (CRP) levels remained elevated. A contrast-enhanced abdominal CT showed two areas of low-density fluid with no enhancement in a mildly enlarged spleen, making it difficult to distinguish abscesses from cysts. Due to relapsing sterile peritonitis, we performed an abdominal ultrasonography, and suspected splenic abscesses due to rapid increase in size. Repeated imaging tests were useful in establishing a diagnosis of splenic abscesses. Considering the persistent elevation of WBC and CRP levels, imaging findings, and episodes of relapsing peritonitis, we comprehensively formed the diagnosis, and performed a splenectomy as a rescue therapy. We should consider the possibility of other infectious foci with persistent inflammation after resolving PD-related peritonitis.

Duodenal-jejunal bypass improves diabetes and liver steatosis via enhanced glucagon-like peptide-1 elicited by bile acids.

BACKGROUND AND AIM: Bariatric surgery not only elicits weight loss but also rapidly resolves diabetes. However, the mechanisms remain unclear. The present study investigates how diabetes and liver steatosis are improved after duodenal-jejunal bypass (DJB) compared with a glucagon-like peptide-1 (GLP-1) analog and correlations between bile acids and GLP-1 secretion. METHODS: We initially determined the effects of bile acids on GLP-1 in vitro and then assigned 12 male 16-week-old Otsuka Long-Evans Tokushima Fatty rats to groups that underwent DJB, a sham operation, or were treated with the GLP-1 receptor agonist, liraglutide (n = 4 each). Blood glucose, insulin, GLP-1, serum bile acids, liver steatosis, and the number of GLP-1 positive cells (L cells) in the small intestine and colon were investigated in the three groups at eight weeks postoperatively. RESULTS: Levels of GLP-1mRNA were upregulated and GLP-1 secretion increased in cells incubated with bile acids in vitro. Weight gain was suppressed more in the DJB than in the sham group in vivo. Diabetes was more improved and GLP-1 levels were significantly higher in the DJB than in the sham group. Serum bile acids were significantly increased, the number of L cells in the ileum was upregulated compared with the sham group, and liver steatosis was significantly improved in the DJB compared with the other two groups. CONCLUSIONS: Duodenal-jejunal bypass might improve diabetes and liver steatosis by enhancing GLP-1 secretion through increasing serum bile acids and the proliferation of L cells in the ileum, compared with liraglutide.

CD133 expression is correlated with poor prognosis in colorectal cancer.

BACKGROUND/AIMS: Cancer stem cells (CSC) was reported to play an important role in various kinds of cancer. CD133 is one of the cancer stem cell markers in solid cancers. However, the correlation between CD133 expression and the clinicopathological factors in colorectal cancer (CRC) remains unclear. METHODOLOGY: Forty patients with CRC who underwent operations were enrolled. Expression of CD133 was investigated by immunohistochemistry (IHC). The staining was observed in the cytoplasm of cancer cells and the patients who have the staining were defined as CD133-positive cases. The patients were divided into two groups: the CD133-positive group (n = 22) and negative group (n = 18). Clinicopathological factors were compared between the two groups. The prognostic factors were investigated by multivariate analysis. RESULTS: In the CD133-positive group, the incidence of lymph node and liver metastasis, lymphatic and venous invasion, as well as the progression of stage of cancer were higher than that in the CD133-negative group. The 5-year survival rate and the disease-free survival rate in the CD133-positive group were lower than that in the CD133-negative group. The multivariate analysis revealed that CD133 expression tended to be an independent prognostic factor. CONCLUSIONS: CD133 expression is correlated with poor prognosis in CRC.

Effect of light irradiation by light emitting diode on colon cancer cells.

BACKGROUND/AIM: Recent studies have demonstrated the efficacy of irradiation from light emitting diodes (LED) for wound healing, anti-inflammation and anticancer therapies. However, little is known about the effects of visible light in colon cancer cells. The purpose of this study was to evaluate the biological response (including gene expression changes) of human colon cancer cells to different wavelengths of LED irradiation. MATERIALS AND METHODS: Human colon cancer cells (HT29 or HCT116) were seeded onto laboratory dishes that were then put on LED irradiation equipment with a 465 nm-, 525 nm-, or 635 nm-LED. Irradiation at 15 or 30 mW was performed 10 min/day, each day for 5 days. The cell counting kit8 was then used to measure cell viability. Apoptosis and expression of several mRNAs (caspase, MAPK and autophagy pathway) in HT29 cultures irradiated with 465 nm LED were evaluated via AnnexinV/PI and RT-PCR, respectively. RESULTS: Viability of HT29 and HCT116 cells was lower in 465 nm-LED irradiated cultures than in control cultures, but viability of HT29 cells did not differ between control cultures and 525 nm-LED or 635 nm-LED irradiated cultures. Moreover, the expression of FAS, caspase-3, capase-8, and JUK were significantly higher in 465 nm-LED irradiated cultures than in control cultures, and expression of ERK1/2 and LC3 was lower in blue-irradiated cells. CONCLUSION: LED irradiation at 465 nm inhibited the proliferation of HT29 cells and of HCT116 cells. Notably, LED irradiation at 465 nm promoted apoptosis inHT29 cultures via the extrinsic apoptosis pathway and the MAPK pathway.

Hybrid technique for laparoscopic incisional ventral hernia repair combining laparoscopic primary closure and mesh repair.

INTRODUCTION: Incisional ventral hernia is one of the most common surgical complications after laparotomy. Laparoscopic repair of incisional ventral hernia has been conducted recently, and the advantages of this procedure have been reported. However, in large orifice cases, the recurrence rate is increased. To improve recurrence rates in large cases, a hybrid method combining laparoscopic primary closure and mesh repair can be applied. MATERIALS AND SURGICAL TECHNIQUE: Monofilament thread was inserted into the abdominal cavity for hernia closure and pulled from the other side of the orifice. The same procedure was performed from the upper side to the lower side without closure, and all thread was placed in line. Both sides of the thread were then introduced to the midline of the incision through a subcutaneous route. This procedure was conducted with an introducer. All threads were tied, and then a mesh was placed. DISCUSSION: Hybrid techniques already combine mini-laparotomy for hernia closure and subsequent laparoscopic intraoperative onlay mesh for reinforcement, but such techniques require laparotomy. In our technique, closure of the linea alba does not require laparotomy. All procedures were performed laparoscopically. This procedure is very easy and safe, and does not require the abdominal cavity to be opened. Thus, hybrid methods are effective for treating cases of incisional hernia involving a large orifice.

Characteristics of internal hernia after gastrectomy with Roux-en-Y reconstruction for gastric cancer.

BACKGROUND: Although the internal hernias have been a huge topic in the field of bariatric surgery, there were a few reports in gastric cancer. The purpose of this study was to analyze the incidence, clinical features, and prevention of internal hernia after gastrectomy for gastric cancer. METHODS: Twelve patients who underwent surgical treatment for internal hernia in our hospital after gastrectomy were analyzed. Features, including incidence, symptoms, and signs, were investigated in detail. RESULTS: The operative procedures for preceding gastrectomies were open distal gastrectomy in three patients, open total gastrectomy in three patients, laparoscopic-assisted distal gastrectomy in two patients, and laparoscopic total gastrectomy in four patients. The most frequent sites of internal hernias were jejunojejunostomy mesenteric defects (five patients) and Petersen's defect (five patients), mesenterium of transverse colon (one patient), and esophagus hiatus (one patient). There was no significant difference between open and laparoscopic preceding gastrectomies. After closure of the mesenteric defect was introduced, no further internal hernias occurred. On CT examination, the whirl sign was present in ten patients on 3D images. CONCLUSIONS: The present data suggest the importance of early recognition and treatment of internal hernia, as well as its prevention by closure of mesenteric defects.

Kampo medicine "Dai-kenchu-to" prevents CPT-11-induced small-intestinal injury in rats.

PURPOSE: The key anticancer agent, CPT-11 (irinotecan hydrochloride), induces severe diarrhea clinically. We investigated the effect of a Kampo medicine, Dai-kenchu-to (DKT), on CPT-11-induced intestinal injuries in rats. METHODS: Twenty-four male Wistar rats were divided into three groups: a control group; a CPT-11 group, given CPT-11 150 mg/kg intraperitoneally for 2 days; and a DKT group, given DKT 300 mg/kg orally for 5 days with CPT-11 150 mg/kg intraperitoneally on days 4 and 5. The rats were killed on day 6. RESULTS: Interleukin (IL)-1ß, IL-12, interferon (IFN)-γ, and tumor necrosis factor-α expression in the small intestine of the CPT-11 group was significantly higher than that of the control group. Interleukin-1ß and IFN-γ expression was improved significantly by DKT (P < 0.05). The number and height of jejuna villi, injury score, and apoptosis index in the CPT-11 group were improved significantly by DKT (P < 0.05). CONCLUSIONS: DKT suppressed CPT-11 induced inflammatory cytokines and apoptosis in the intestinal mucosa and maintained the mucosal integrity.

A case of perinephric liposarcoma which recurred ten years later from the initial operation.

A 58-year old man was referred to our hospital for treatment of an abdominal mass. As for him, tumor resection with right nephrectomy had been performed ten years ago for a giant well-differentiated perinephric liposarcoma. CT examination showed a huge tumor shadow in the abdominal cavity. Abdominal MRI examination showed a 15 × 8 cm tumor with almost high signal intensity on the T2 weighted images. At laparotomy, a large bulky retroperitoneal tumor pointed out before an operation was found. Surgical extirpation of the tumor was performed. Besides, several tumors of the thumb head size were detected into right retroperitoneal fatty tissue. The right side mesocolon and the tumors were not able to exfoliate, therefore right hemicolectomy was performed. Histological features showed dedifferentiated liposarcoma. The postoperative course was uneventful. But eight months after surgery, he was admitted again for treatment of a 4 × 3 cm retroperitoneal tumor. Extirpation of the tumor was performed. Histological finding of this tumor also showed dedifferentiated liposarcoma. Dedifferentiation, occurring in 15% of the well-differentiated liposarcomas, sometimes may develop later. Long-term detailed follow-up is necessary for well-differentiated liposarcoma.

Gastric cancer with choriocarcinoma and yolk sac tumor components: case report.

Choriocarcinoma- and yolk sac tumor-like differentiation have rarely been reported in gastric cancers. We report a case of gastric adenocarcinoma, concurrently possessing choriocarcinoma and yolk sac tumor components, of a 74-year-old man. A hemorrhagic, 11 × 8 × 3 cm, tumor with ulceration was located in the body and pre-pylorus of the stomach. Histological examination of the resected specimens demonstrated intermingled proliferation of three different components, namely, adenocarcinoma, choriocarcinoma and yolk sac tumor, which were immunoreactive for carcinoembryonic antigen (CEA), beta-subunit of human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP), respectively. Gastric cancers with germ cell tumor components are uncommon and this is the second reported case of gastric cancer with choriocarcinoma and yolk sac tumor components.

Gastric emptying in Billroth-I and Roux-en-Y reconstruction after distal gastrectomy using C-acetate breath test.

BACKGROUND/AIMS: Billroth-I and Roux-en-Y procedures have been applied generally as reconstruction techniques after distal gastrectomy. There have been few reports regarding the physiological differences of these two procedures. We compared gastric emptying after Roux-en-Y procedure with the Billroth-I procedure using the 13C-acetate breath test. METHODOLOGY: Eleven patients who underwent distal gastrectomy, using reconstruction procedures of Billroth- I (B-I group: n=7) and Roux-en-Y (R-Y group: n=6), and 4 healthy volunteers (Control group) were studied. After ingestion of 200mL of liquid diet labelled with 100mg 13C-acetate, breath samples were collected every 5-15 minutes for 3 hours. The analysis of 13C-acetate enrichment was measured using infrared spectrometer. RESULTS: Mean breath-Tmax of B-I group (14.2min) and R-Y group (13.0min) were significantly shorter compared with that of the control group (42.5min). Mean breath-T1/2 of B-I group (76.8min) and R-Y group (80.2min) were significantly shorter compared with that of the control group (133.3min). Mean breath-Cmax of B-I group (60.1min) and R-Y group (59.3min) were significantly higher than that of the control group (27.6min). CONCLUSIONS: 13C-acetate breath test was useful to evaluate gastric emptying. There were no differences in gastric emptying for both Billroth-I and Roux-en-Y reconstruction.

Coexistent poorly-differentiated neuroendocrine cell carcinoma and non-invasive well-differentiated adenocarcinoma in tubulovillous adenoma of the rectum: report of a case.

A 74-years old man was referred to our hospital for treatment of a rectal mass. Colonoscopy revealed villous tumor covering all the lower rectal lumen. Biopsy yielded a diagnosis of adenoma. CT examination showed tumor shadows of the rectum and the liver. Pelvic MRI examination showed a 10.5×8×7 cm tumor with high signal intensity on the T2 weighted images in the rectum. Rectosigmoidectomy with lymph node dissection was performed with the diagnosis of rectal cancer that metastasized to the liver. Histological and immuno- histochemical features showed coexistent poorly-differentiated small cell neuroendocrine cell (NEC) carcinoma and non-invasive well-differentiated adenocarcinoma in tubulovillous adenoma. However the chemotherapy with FOLFOX and Bevacizumab was performed postoperatively, the patient died in cancer 3 months after surgery. Rectal poorly-differentiated NEC carcinomas are thought to be a tumor with a high malignant potential. Recently, the UICC TNM classifications of malignant tumors, 7th edition and the Guidelines for colorectal NEC tumors of European Neuroendocrine Tumor Society have been published. They would be evaluated, and effective multimodal therapy for NEC carcinomas should be established.

Laparoscopic removal of a foreign body in the pelvic cavity through one port using a flexible cholangioscope.

BACKGROUND: More than two trocar ports 12 mm in diameter were usually used to remove a foreign body from the peritoneal cavity using laparoscopic surgery. We designed a method of laparoscopic removal through a single port 5 mm in diameter and a flexible cholangioscope. PATIENTS AND METHODS: The patient had a ventriculoperitoneal shunt (V-P shunt) catheter implanted for hydrocephalus of unknown cause in his 40s. Endoscopic marsupialization of the third ventricle was performed because of functional failure of the V-P shunt catheter 7 years after the implantation. A falling off of the V-P shunt catheter into the pelvic space was detected, and laparoscopic removal of the V-P shunt catheter was performed. A laparoscope was inserted through a trocar port 5 mm in diameter to confirm the location of the V-P shunt catheter following replacement of the flexible cholangioscope to grasp the catheter. The catheter was held using a snare catheter through the cholangioscope. The V-P shunt catheter was removed by pulling through the trocar port with the flexible cholangioscope. CONCLUSION: Laparoscopic removal is a good technique for removal of a foreign body in the peritoneal cavity. It enables one-port laparoscopic removal using a flexible cholangioscope.

Effect of splenectomy on antitumor immune system in mice.

BACKGROUND: The influence on the antitumor immune system after splenectomy in vivo are controversial. CD4+CD25+Foxp3+T-cells (regulatory T-cell: reg T) and natural killer (NK) cells play important roles in immunological tolerance and antitumor immunity. The influence of splenectomy on the antitumor immune system was evaluated in a metastasis induced mouse model. MATERIALS AND METHODS: Experiment 1, splenectomy in a cancer-free model. The mice were divided into two groups, one control, and the other splenectomy group. At days 4, 7 and 10 after splenectomy, the mesenteric lymph node, the liver and the lung were harvested. The lymph nodes were analyzed by flow cytometric analysis and the number of reg T-cells and NK cells were calculated. Foxp3 mRNA in the liver and the lung was evaluated by reverse transcriptional polymerase chain reaction (RT-PCR). Experiment 2, splenectomy in a liver metastasis model. Colon 26 cells were injected into the spleen of mice and the mice were divided into two groups, a spleen preserved group, and a splenectomy group. Splenectomy was performed at day 4 after injection. At days 7 and 10 after injection, flow cytometric analysis, and at day 10 RT-PCR were performed. Ten days after injection, the number of liver metastases (>1 mm) was counted. RESULTS: Experiment 1, in the splenectomy group the flow cytometric analysis showed a significant decrease in the number of reg T and NK cells in the mesenteric lymph nodes compared with the control group. In the splenectomy group, the Foxp3 mRNA increased significantly in the liver at day 10, and in the lung at days 4 and 7. Experiment 2, liver metastasis was observed in the splenectomy group. Flow cytometric analysis showed that splenectomy did not affect the number of reg T at day 7 and day 10. The number of NK cells increased in the splenctomy group at day 7, but at day 10, there was no significant difference between the groups. RT-PCR showed that at day 10, the Foxp3 mRNA in liver increased in the splenectomy group. CONCLUSION: The spleen plays a very important role in the antitumor immune system and splenectomy enhances liver metastasis through the increase of Foxp3 mRNA in the liver.

Does Roux-en Y reconstruction with jejunal pouch after total gastrectomy prevent complications of postgastrectomy?

BACKGROUND/AIMS: To evaluate the efficacy of a jejunal pouch after a total gastrectomy with Roux-en Y reconstruction. METHODOLOGY: Thirty patients with gastric cancer who had a total gastrectomy as a radical operation and had no recurrence were enrolled in this study. The jejunal pouch was added to Roux-en Y reconstruction in 15 patients (J-pouch group) and was not added in the other 15 patients (Roux en-Y group). A questionnaire survey which consisted of dietary intake, postprandial abdominal complaints and body weight, blood examination (hemoglobin, total protein, albumin), were conducted. The 99mTc-DTPA with semi-liquid diet emptying test and the manometry in the jejunal pouch were evaluated in 12, 2 of the J-pouch group, respectively. RESULTS: There were no significant differences between the two groups in the questionnaire survey and blood examination. The half emptying time (T1/2) of 99mTc-DTPA was over 60 minutes in 9 of the 12 J-pouch group. The manometric study did not reveal the effective contraction of the jejunal pouch. Bypass operation was necessary due to marked delay of emptying in the jejunal pouch for one patient in the J-pouch group. CONCLUSIONS: The advantage of adding a jejunal pouch to Roux en-Y reconstruction was not proven in this study.