Non-surgical treatment of gastric emphysema with intraabdominal free gas and hepatic portal venous gas: Lessons from a rare case.

We herein describe a case of an 83-year-old man who presented with epigastralgia, vomiting, and abdominal distention. The physical abdominal examination revealed mild tenderness. Computed tomography revealed intramural gastric gas spread throughout the stomach, intraabdominal free gas, and hepatic portal venous gas. We diagnosed gastric emphysema with intraabdominal free gas and hepatic portal venous gas. We selected a wait-and-watch approach because physical examination did not show any peritoneal signs, although the radiological examinations showed remarkable findings. As a result, he received conservative therapy with fasting, intravenous infusion of antibiotics, and gastric decompression by nasogastric intubation. The patient was relieved of the symptoms, and follow-up computed tomography showed that all the abnormal gas disappeared soon after the treatment. In conclusion, the intramural gastric gas even with both intraabdominal free gas and hepatic portal venous gas does not always require surgical intervention. In case clinicians including general surgeons and physicians encounter intraabdominal free gas with hepatic portal venous gas, gastric emphysema should be considered in the different diagnosis. Lack of knowledge may lead to misdiagnosis, which may result in unnecessary surgical intervention.

Premedication with fast-acting oxycodone hydrochloride hydrate effectively reduced oxaliplatin-induced severe vascular pain.

Oxaliplatin is a platinum-based chemotherapeutic agent that holds a prominent position in the treatment of colorectal and gastric cancers. However, severe oxaliplatin-related vascular pain can be problematic for patients. Here we describe seven patients who experienced severe vascular pain caused by oxaliplatin administration. All seven patients were treated with capecitabine and oxaliplatin or capecitabine plus oxaliplatin with bevacizumab as an adjuvant or a treatment for recurrent colorectal cancer, respectively. Patients experienced intolerable vascular pain during oxaliplatin administration, which continued for several days. Moreover, vascular pain also induced insomnia and appetite loss in all patients. We recommended implantation of a central venous (CV) port to the patients; however, all patients declined this treatment. In addition, various known countermeasures were taken, but were ineffective. Therefore, patients were orally administered oxycodone hydrochloride hydrate (Oxinorm®) 45 min prior to oxaliplatin administration. This pretreatment successfully reduced vascular pain and improved subsequent chemotherapy. Oxinorm® is a fast-acting opioid that can be an effective and practical option for severe vascular pain induced by oxaliplatin. The present report is the first description that emphasizes the usefulness of Oxinorm® to overcome the vascular pain induced by administration of oxaliplatin via a peripheral vein.

Does massive intraabdominal free gas require surgical intervention?

We describe a rare case of an 81-year-old man who presented with severe epigastralgia. A chest radiograph showed massive free gas bilaterally in the diaphragmatic spaces. Computed tomography (CT) scan also showed massive free gas in the peritoneal cavity with portal venous gas. We used a wait-and-see approach and carefully considered surgery again when the time was appropriate. The patient received conservative therapy with fasting, an intravenous infusion of antibiotics, and nasogastric intubation. The patient soon recovered and was able to start eating meals 4 d after treatment; thus, surgical intervention was avoided. Thereafter, colonoscopy examination showed pneumatosis cystoides intestinalis in the ascending colon. On retrospective review, CT scan demonstrated sporadic air-filled cysts in the ascending colon. The present case taught us a lesson: the presence of massive intraabdominal free gas with portal venous gas does not necessarily require surgical intervention. Pneumatosis cystoides intestinalis should be considered as a potential causative factor of free gas with portal venous gas when making the differential diagnosis.

Overexpression of TSC-22 (transforming growth factor- ß-stimulated clone-22) causes marked obesity, splenic abnormality and B cell lymphoma in transgenic mice.

In this study, we generated transgenic (Tg) mice, which overexpressed transforming growth factor (TGF)-ß stimulated clone-22 (TSC-22), and investigate the functional role of TSC-22 on their development and pathogenesis. We obtained 13 Tg-founders (two mice from C57BL6/J and 11 mice from BDF1). Three of 13 Tg-founders were sterile, and the remaining Tg-founders also could generate only a limited number of the F1 generation. We obtained 32 Tg-F1 mice. Most of the Tg-mice showed marked obesity. Histopathological examination could be performed on 31 Tg-mice; seventeen mice died by some disease in their entire life and 14 mice were killed for examination. Most of the Tg-mice examined showed splenic abnormality, in which marked increase of the megakaryocytes, unclearness of the margin of the red pulp and the white pulp, and the enlargement of the white pulp was observed. B cell lymphoma was developed in 10 (71%) of 14 disease-died F1 mice. These results indicate that constitutive over-expression of TSC-22 might disturb the normal embryogenesis and the normal lipid metabolism, and induce the oncogenic differentiation of hematopoietic cells.

Repeated Duodenal Stump Perforation Using a Stapling Device Following Subtotal Gastrectomy With Roux-en-Y Reconstruction for Advanced Gastric Cancer: Lessons From a Rare Case.

Closure of the duodenal stump using a stapling device is commonly applied in Roux-en-Y reconstruction after gastrectomy. However, serious and possibly fatal duodenal stump perforation can develop in extremely rare cases. We describe a case of subtotal gastrectomy with Roux-en-Y reconstruction followed by repeated duodenal stump perforations. A 79-year-old man with a long history of diabetes and hypertension was admitted to our institution with epigastralgia and right hypochondralgia. Computed tomography and an upper gastrointestinal imaging series revealed remarkable wall thickening of the gastric antrum and corpus. Upper endoscopy also showed a giant ulcerative lesion in the same area. The lesion was confirmed by histology to be poorly differentiated adenocarcinoma. The patient underwent open subtotal gastrectomy with Roux-en-Y reconstruction. However, duodenal stump perforation occurred repeatedly on postoperative days 1, 3, and 19, which caused peritonitis. The patient was kept alive through duodenal stump repair, an additional resection using a stapling device, and repeated drainage treatments; but he suffered considerable morbidity due to these complications. We report a case of a life-threatening duodenal stump perforation after subtotal gastrectomy, highlighting lessons learned from the profile and clinical course. Abdominal surgeons should be aware of the possibility of this serious complication of duodenal stump perforation, and be able to perform immediate interventions, including life-saving reoperation.

A giant lymphatic cyst of the adrenal gland: report of a rare case and review of the literature.

Lymphatic type of adrenal cysts is most common; however, this type of endothelial cyst is quite rare in excessively large adrenal cysts. A 37-year-old Japanese woman was admitted to our institution with distension of her left flank and the upper quadrant of her abdomen. Abdominal ultrasonography revealed a cystic lesion with a homogenous anechoic texture, and measuring 21 cm in diameter. Computed tomography and magnetic resonance imaging displayed a giant cystic lesion adjacent to the liver, pancreas, kidney, and spleen. The origin of the cyst was not identified. We were not able to make a preoperative diagnosis; therefore, the patient underwent resection of the mass by open laparotomy for therapeutic diagnosis. Intraoperatively, the mass was identified to be cystic and adhered to the left adrenal gland. It was filled with more than 2000 mL of serous brown-red fluid. The content of the cyst contained no atypical cells on cytological examination. The wall of the cyst was composed of a lining of a single layer of lymphatic vessel-derived cells, and the cyst was pathologically classified as a true cyst. No abdominal symptoms were observed and a postoperative radiological work-up showed no evidence of recurrence during a 6-year follow-up period. We describe a case of a patient with a giant lymphatic cyst of the adrenal gland. The preset data suggest that surgeons should decide treatment strategy for large adrenal cysts in consideration of hormonal function, degree of size, and possibility of malignancy.

Serum alpha-fetoprotein level per tumor volume reflects prognosis in patients with hepatocellular carcinoma after curative hepatectomy.

BACKGROUND/AIMS: The clinical usefulness of alpha-fetoprotein (AFP) in the management of hepatocellular carcinoma (HCC) remains controversial. This study aimed to assess the prognostic reliability of serum AFP levels per tumor volume (AFP/volume) after curative resection. METHODOLOGY: A total of 196 patients with HCC were analyzed with reference to serum AFP levels at diagnosis. Clinicopathological data included presence of cirrhosis, indocyanine green retention rate (ICGR15), tumor size and number of HCCs. Tumor volume for HCCs was calculated preoperatively by Computed tomography volumetry, and AFP/volume was calculated by dividing serum AFP level by tumor volume. RESULTS: No significant correlation between serum AFP levels and presence of cirrhosis or ICGR15 was observed. A significant correlation existed between serum AFP levels and both size (P=0.001, r=0.276) and number (P=0.023, r=0.186) of HCCs. The 5-year survival rates in patients with low (< 200 ng/mL) and high (> or = 200 ng/mL) serum AFP level were 85.0% and 36.0%, respectively. AFP/volume tended to be negatively associated with survival period (p=0.084, r = -0.346), and a significant negative correlation existed between AFP/volume and disease-free survival period (p=0.001, r = -0.347). Median values of AFP/ volume in patients who displayed recurrence by 1 year and 6 months were 11.51 and 20.05, respectively. CONCLUSIONS: AFP/volume represents a better prognostic indicator for patients with HCC than serum AFP value alone. In particular, patients with AFP/volume > 20.0 are likely to experience recurrence within 6 months after curative hepatectomy.

Liver transplantation in Diego blood disparity: a case report.

The Di antigen in the Diego blood type system is an anthropologic marker of Mongoloids. Here, we report the first case of liver transplantation involving donor/recipient Diego blood type disparity. The recipient was a 58-year-old woman who had developed fulminant hepatic failure, and her 32-year-old daughter was a candidate donor. The recipient and the donor were both ABO blood type O, and were Di (a- b+) and Di (a+ b+), respectively, in the Diego blood system. Living-related liver transplantation was performed, and immediate graft function was obtained. No signs of humoral rejection were observed on postoperative days one to four. Biopsy performed on postoperative days 10, 63, and 87 because of elevation of the serum bilirubin level showed no signs of humoral rejection. In conclusion, liver transplantation can be performed successfully in cases of Diego blood type disparity.

Malignant stromal tumor, so called "gastrointestinal stromal tumor", with rhabdomyomatous differentiation occurring in the gallbladder.

Gastrointestinal stromal tumors (GISTs) constitute the largest category of primary nonepithelial neoplasms of the gastrointestinal tract. It is extremely rare that this tumor occurs in the bile tract, and only a few cases have been reported. Immunohistochemically, the tumor cells revealed a phenotype similar to Cajal cells, occasionally with differentiation to smooth muscle cells or neural cells. We present a case of malignant stromal tumor similar to GISTs with rhabdomyomatous differentiation of the gallbladder in a 68-year-old woman. The resected tumor was predominantly composed of spindle cells with rhabdomyomatous differentiation. Immunohistochemical study revealed diffuse staining of tumor cells using vimentin despite negative staining for desmin or S-100. This indicated a mesenchymal origin of the cells without smooth muscle or neuronal differentiation. Myoglobin-positive cells, in which phosphotungstic acid hematoxylin staining revealed cross striations of the cytoplasm, suggested rhabdomyomatous differentiation. Diffuse positivity for KIT in the cells suggested that the pathogenesis of this tumor may resemble that of GIST. The tumor may have derived from a mesenchymal stem cell that had undergone partial rhabdomyomatous differentiation.

Laparoscopic removal of an intragastric foreign body with endoscopic assistance.

We report the successful laparoscopic removal of an intragastric foreign body. A 57-year-old woman who had accidentally swallowed her own partial denture was referred to our hospital for its removal. Laparoscopic removal of the foreign body was urgently performed with the assistance of oral endoscope, following an earlier failed endoscopic removal associated with subcutaneous and mediastinal emphysema. The foreign body was removed from the stomach through a gastrotomy. There were no perioperative complications. The patient was uneventfully discharged on the ninth postoperative day. Laparoscopic removal of an intragastric foreign body is a feasible and safe treatment, and can be an alternative choice following failed endoscopic removal.

Identification of genes differentially expressed in a newly isolated human metastasizing esophageal cancer cell line, T.Tn-AT1, by cDNA microarray.

We isolated a metastasizing human esophageal squamous cell carcinoma (SCC) cell line, T.Tn-AT1, from a parental non-metastasizing cell line, T.Tn, by in vitro selection and by use of a nude mouse orthotopic inoculation model. Then, we compared the expression profiles of 9206 genes in T.Tn-AT1 and T.Tn by cDNA microarray analysis. The gene expression profiles of T.Tn and T.Tn-AT1 were very similar, and only 34 genes showed more than 3-fold differential expression. Among the 34 genes, 29 genes were down-regulated and only 5 genes were up-regulated in T.Tn-AT1 cells. Subsequently, we confirmed the expression levels of 14 of the 34 genes in T.Tn and T.Tn-AT1 cells by means of reverse transcription-polymerase chain reaction. The expression of 8 genes (KAL1, HPGD, NDN, REG1A, CXCR4, SPOCK, DIAPH2 and AIF1) was down-regulated and that of one gene (VNN2) was up-regulated in T.Tn-AT1 cells. These 9 genes encoded proteins associated with metastatic processes, such as adhesion, migration, inflammation, proliferation, and differentiation. Thus, these genes might regulate the metastasis of esophageal SCC, and could be predictive markers for lymph node metastasis of esophageal SCC.

Evaluation of cell proliferation and apoptosis in Helicobacter pylori gastritis using an image analysis processor.

BACKGROUND: Infection of the gastric mucosa by helicobacter pylori is primarily responsible for gastritis, gastric ulcer, adenocarcinoma, and lymphoproliferative disorders. H. pylori appears to accelerate apoptosis and the proliferation of the gastric epithelium directly or indirectly. To precisely assess the proliferative and apoptotic profile of .H pylori-infected gastric mucosa, a quantitative imaging system is now required. METHODS: Fifty-two patients with H. pylori gastritis were the subjects of the study. Biopsy materials were taken from at least two sites (usually three to five sites) including the antrum and corpus. The grade of gastritis was evaluated by the updated Sydney System. The proliferative and apoptotic profile was examined by Ki-67 immunohistochemistry and by a terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick end-labeling method. In addition, Ki-67-positive cells were quantitated by an image processor for analytical pathology (IPAP) system. RESULTS: H. pylori density and polymorphonuclear neutrophil activity were significantly decreased after H. pylori eradication ( P< 0.0001). Chronic inflammation (P< 0.0001) and lymphoid follicle numbers ( P < 0.0005) were also significantly decreased after the eradication. Glandular atrophy and intestinal metaplasia were slightly decreased after eradication, but the decrease did not reach the significant level. the Ki-67 labeling index was significantly decreased after the eradication P< 0.0001). The apoptosis index was also decreased after the eradication, but this decrease did not reach the significant level ( P = 0.06). CONCLUSION: our data suggest that the activation of proliferative cells and induction of apoptosis in the gastric mucosa is a response to H. pylori-induced mucosal damage. Moreover, IPAP may be a useful technology for evaluating the results of immunohistochemistry, and it could provide quantitative and reliable data for studying H. pylori gastritis.

Evaluation of the chemosensitivity of head and neck cancer cells based on the diverse function of mutated-p53.

Pre-therapeutic evaluation of p53 gene is very important for treating patients with head and neck cancer. However, the analysis for p53 gene has generally been done by immunohistochemistry, polymerase chain reaction (PCR)-single strand conformation polymorphism (SSCP) and direct sequencing. Functional analysis system for p53 transcriptional activity in mammalian cells is now required. We developed a functional analysis system for p53 transcriptional activity in cancer cells. We used two human head and neck cancer cell lines harboring mutated p53 gene, HSG (Asn30Ser) and TYS (Asp281His), and a human osteosarcoma cell line, Saos-2 as a control. We transfected these cells with luciferase reporter plasmids containing promoter sequence of p53 target genes (p21waf1, BAX, MDM2, p53AIP1 or PUMA). After treating the cells with chemotherapeutic drugs, alteration of the luciferase activity was measured. In HSG cells, none of the target gene promoters was activated by treatment with chemotherapeutic drugs. In TYS cells, p21waf1 promoter was markedly activated by treatment with chemotherapeutic drugs, but Bax and p53AIP1 promoter was not activated. This type of mutated-p53 in TYS cells prevents cell death from DNA damage, and probably accumulates genetic alterations and accelerates the malignant progression of the cells by DNA damaging therapy. Thus, analysis for the diverse function of mutated-p53 may help to determine the therapeutic strategy, especially for chemotherapy and radiation in the individual patients with head and neck cancer.

Biliary papillomatosis arising in a congenital choledochal cyst: report of a case.

We report a rare case of biliary papillomatosis arising in a congenital choledochal cyst, with an anomalous junction of the pancreatobiliary ductal system (AJPBDS). A 50-year-old woman was admitted to our department with epigastralgia, and imaging studies showed two masses in the cystic common bile duct and an AJPBDS. We made a preoperative diagnosis of biliary tract cancer, considering the size of the masses and the presence of the AJPBDS, and performed a pylorus-preserving pancreatoduodenectomy. The resected specimen contained two papillary tumors, which were subsequently diagnosed as benign papillomas. Histopathological and oncological examinations indicated that the lesions were involved in the development and progression of carcinogenesis because a point mutation of the K- ras gene and overexpression of p53 protein were detected. These findings suggest that biliary papillomatosis is a precancerous lesion induced by an AJPBDS.

Molecular and genetic characterization of a non-metastatic human esophageal cancer cell line, T.Tn expressing non-functional mutated p53.

Lymph node metastasis is commonly found in esophageal squamous cell carcinoma (SCC). In this study, we examined the molecular and genetic characteristics of a human esophageal SCC cell line, T.Tn. T.Tn cells formed tumors at s.c. tissue in nude mice when inoculated with Matrigel, but did not metastasize to any organs. T.Tn cells expressed low level of proMMP2 and a trace level of proMMP9. However, T.Tn cells expressed high level of TIMP1 and TIMP2, and beta-catenin and E-cadherin. We found a point mutation of p53 gene at codon 213 (CAT-->CGT) in T.Tn cells. The mutated-p53 protein did not show transcriptional activity on p21(waf1), MDM2 and Bax promoters. Thus, T.Tn cells are low tumorigenic and weakly invasive but not metastasizing in nude mice, and T.Tn cells are suitable parental cells for establishing a model system to study invasion and metastasis of esophageal SCC.

Evaluation of the malignant potential of aberrant crypt foci by immunohistochemical staining for beta-catenin in inflammation-induced rat colon carcinogenesis.

We previously showed that colitis enhanced the development of cancer and aberrant crypt foci (ACF) in 1,2-dimethylhydrazine (DMH)-induced colon carcinogenesis in Fischer 344 rats. In this study, we examined the effect of two different anti-inflammatory drugs [non-steroidal anti-inflammatory drugs (NSAIDs: Fenbufen) and a platelet activating factor-receptor antagonist (PAF-RA)] on the inflammation-induced rat colon carcinogenesis. Furthermore, we examined the expression and the localization of beta-catenin protein, and the proliferating cell nuclear antigen (PCNA)-labeling index (LI) in ACF and cancer. PAF-RA significantly decreased the incidence of ACF in the rats (p<0.05), but Fenbufen did not affect the incidence of ACF and cancer. In most of the ACF (91%), beta-catenin was localized at the cell membrane like in normal colon epithelium. In about 9% of the ACF, beta-catenin was overexpressed not only on the cell membrane but also in the cytoplasm. In all of the cancer cells, beta-catenin was overexpressed in the nucleus. When we compared the PCNA-LI in the ACF showing normal beta-catenin expression pattern with that in the ACF showing abnormal beta-catenin expression pattern (overexpression in cytoplasm), there was no significant difference of the PCNA-LI in these two different types of ACF. These findings suggest that immunohistochemical staining of ACF for beta-catenin can evaluate the malignant potential of ACF, and that PAF-RA can be used for preventing the development of ACF in inflammation-induced carcinogenesis.