Endoscopic submucosal dissection for rectal tumors.

BACKGROUND AND STUDY AIM: Endoscopic submucosal dissection (ESD) has recently been developed for one-piece resection of gastric tumors. In order to improve patients' quality of life, it may be desirable to use the same technique for rectal tumors. METHODS: 35 consecutive patients with rectal tumors were enrolled. ESD was carried out using the same technique as for the stomach. The efficacy, technical feasibility, operation time, complications, and follow-up results were assessed. RESULTS: The mean size of the epithelial tumors was 26.2 +/- 14.0 mm, and the rates of one-piece resection and one-piece resection with tumor-free margins were 73.3% (22 of 30) and 70.0% (21 of 30), respectively. The median operation time was 70 min (range 8-360 min). All five carcinoid tumors were completely resected. No patient needed blood transfusion or had the complication of problematic bleeding. Perforation during ESD occurred in one patient (2.9%), who was managed with conservative medical treatment after endoscopic closure of the perforation. Excluding seven patients, who either underwent additional surgery or whose follow-up period was less than 1 year, all 23 patients with epithelial tumors were free of recurrence during a mean follow-up period of 25.7 months (range 12-53 months). CONCLUSIONS: ESD was thus found to be feasible for the treatment of rectal tumors, with promising results although the follow-up periods were short. ESD may therefore be indicated for rectal tumors which are not resectable en bloc by conventional procedures, in order to improve the patients' quality of life.

Endoscopic submucosal dissection for early gastric cancers and large flat adenomas.

BACKGROUND AND STUDY AIM: Endoscopic submucosal dissection (ESD) is a new diagnostic and treatment technique for early gastric cancer (EGC). The present study aims to identify the technical feasibility, operation time, and complications associated with ESD. METHODS: We reviewed the patients who underwent ESD for EGCs at Maebashi Red Cross Hospital. RESULTS: There were 160 patients with 171 EGCs treated by ESD. The mean age was 71.4 +/- 8.9 years (median 72). The rate for one-piece resection with tumor-free margins was 94.2 % (161/171), and was 93.2 % (82/88) for large lesions (> 20 mm) and 92.1 % (35/38) for ulcerative lesions. The median operation time was 80 min (range 10-600 min). Evidence of immediate bleeding was found in 2.9 % (5/171), delayed bleeding was seen in 7.6 % (13/171), and perforation was observed in 3.5 % (6/171) of the lesions. All patients with complications, including perforation, were successfully treated endoscopically. There were no local or distant metastases in the lesions which met our indication criteria for ESD. CONCLUSION: The present study shows the technical feasibility of ESD, which provides the capability of one-piece resection even in large and ulcerative lesions.

Primary biliary cirrhosis complicated with sigmoid colonic varices: the usefulness of computed tomographic angiography.

Gastroesophageal varices are the major complication of portal hypertension. Ectopic varices develop in various organs such as the duodenum, colon, and gallbladder. However, varices other than at gastroesophageal or rectal sites is a rare entity. We report a 53-year-old patient with primary biliary cirrhosis complicated by sigmoid colonic varices. Computed tomographic angiography was useful to understand the entire status of the varices.

Hepatocellular carcinoma complicated by hemothorax.

Although hemoperitoneum is a well-known cause of death induced by rupture of hepatocellular carcinoma (HCC). hemothorax caused by rupture of HCC has not been adequately described. We report here a 64-year-old woman who died of bleeding from pleural wall metastasis of HCC. She presented with liver failure and sudden-onset hypotension, and on the same day, she died of hypovolemic shock associated with liver failure. Autopsy revealed HCC metastatic to the lungs and right pleura and 21 of bloody pleural effusion in the right side. The cut surface of the metastatic nodule in the right pleura was filled with coagulated blood and necrotic tissue. We concluded that the pleural metastasis had ruptured and caused the right hemothorax. We discuss reported cases of HCC complicated by hemothorax.

Evaluation of twice-daily administration of interferon-beta for chronic hepatitis C.

To improve the efficacy of interferon (IFN) in the treatment of chronic hepatitis C, administration of IFN-beta twice per day was evaluated. Thirty-eight patients with chronic hepatitis C (26 males and 12 females, aged 25-67 years) were included. Patients were treated with a new protocol that included twice-daily treatment with IFN-beta. Three million units (MU) of IFN-beta was administered twice daily every day for 4 weeks followed by 10 MU of IFN-alpha2b, every day for 2 weeks and then three times a week for 18 weeks (total IFN-beta, 148 MU; IFN-alpha2b, 680 MU). Complete responders (CR) were defined by alanine aminotransferase levels that normalized within 6 months after completion of IFN therapy and remained normal for more than 6 months, and by serum hepatitis C virus (HCV) RNA levels that became negative as determined using the Amplicor assay. Twenty-one of 38 (55.3%) patients were CR. Nine of 21 (42.9%) patients with HCV serotype 1 were responders compared with nine of 12 (75.0%) patients with HCV serotype 2. In patients with an HCV titre greater than 1 million equivalents ml-1 (1 MEq ml-1), nine of 24 (37.5%) responded, and in patients with HCV titres less than 1 MEq ml-1, 12 of 14 (85.7%) responded. In patients with HCV serotype 1 and greater than 1 MEq ml-1 HCV RNA, four of 15 (26.7%) responded to IFN. Two-thirds (66.7%) of the patients who became negative for HCV RNA after 2 weeks of therapy responded, while 72.7% of those with positive HCV RNA after 2 weeks of therapy were non-responders. Proteinuria was frequently observed as an adverse effect of twice-daily administration of IFN-beta. The combination of twice-daily administration of IFN-beta for 4 weeks followed by IFN-alpha showed a high response rate in patients with chronic hepatitis C, but in patients with both serotype 1 and a high titre of HCV RNA, response rates were still low. Thus, the HCV RNA titre 2 weeks after starting therapy with IFN was useful for predicting the eventual response to IFN.

Nausea and vomiting induced by arterial chemo-embolization in patients with hepatocellular carcinoma and the antiemetic effect of ondansetron hydrochloride.

To determine the incidence of nausea and vomiting and the antiemetic effect of ondansetron hydrochloride (OND) in patients with hepatocellular carcinoma treated with arterial chemo-embolization, we studied 59 patients with hepatocellular carcinoma who were treated with transcatheter arterial embolization (TAE) or lipiodolized transcatheter arterial infusion (L-TAI). We investigated the incidence of nausea and vomiting and the amount of food intake when TAE or L-TAI was performed. All patients who experienced nausea and vomiting received OND administered prophylactically at the time of the next TAE or L-TAI to evaluate the antiemetic effect of the drug. Cumulative rates of nausea and vomiting during the week following arterial chemo-embolization were 44.8% and 27.6%, respectively. There was a tendency for the incidence to be higher in patients treated with the anticancer agent zinostatin stimalamer (SMANCS) than in those treated with epirubicin hydrochloride (EPI). Regarding food intake, 53.1% of the patients stated that they ate "half or more than half" of the food provided on the day of arterial chemo-embolization. The rate improved as time went on. In 5 patients who experienced nausea and vomiting at the time of arterial chemo-embolization, nausea and vomiting were inhibited satisfactorily by OND. When arterial chemo-embolization was performed, antiemetic treatment for approximately 3 days was necessary to improve patients' quality of life (QOL) to an acceptable level, and OND was found to be effective for the purpose in our 5 patients who had experienced nausea and/or vomiting at the previous treatment.

Survival of patient with late onset hepatic failure by living-related liver transplantation from maternal donor with incompatible blood type.

A 14-year-old girl with blood type B with late onset hepatic failure (LOHF) of unknown cause has survived through living-related liver transplantation (LRLT). No hepatitis virus, including HAV, HBV, HCV, and HGV, was positive at the onset of LOHF. Autoimmune hepatitis was thought to be the cause because of positive results for serum anti-nuclear antibody at 80 times dilution and elevated gamma-globulin, but treatment with glucocorticoid did not suppress the progressive hepatic failure. Supportive therapy, including pulse therapy with 1g methylprednisolone for 3 days, ursodesoxycholic acid, branched-chain amino acid, and azathioprine did not resolve the hepatic failure. She was treated by repeated plasmapheresis and plasma absorption for 10 months, and then received the left lobe of her mother's liver. (Her mother's blood type was AB). The patient had been well, being treated with tacrolimus and prednisolone, although the serum titer of anti-blood type B antibody was high just after LRLT and mild liver dysfunction continued for more than 3 years after LRLT. Follow-up biopsy 3 years after LRLT revealed chronic hepatitis and progression to liver cirrhosis. Re-transplantation is now under consideration; the patient is now aged 19 years.

Steroid hormone-dependent overexpression of cytochromes P450 2A in liver tumors of TGF alpha transgenic male mice.

To clarify the mechanism underlying the male preference of liver tumor in transforming growth factor (TGF) alpha transgenic mice, we analyzed the sexually dimorphic expression of two P450s, i.e., female-specific mouse 15 alpha hydroxylase P450 (2A4) and coumarin 7-hydroxylase P450 (2A5). The expression of 2A4 mRNA in the livers of both transgenic and nontransgenic males was low compared with that in females. P450 2A5 mRNA in the transgenic males was slightly elevated in the adjacent non-tumorous tissues and dramatically elevated in the tumor compared with that in nontransgenic male liver. The activity of P450 2A5 was higher in females than in males in control and transgenic mice but the difference was smaller in the transgenic mice. The activity of P450 2A5 was exceptionally high in liver tumors of transgenic males, as indicated by mRNA expression. These results suggest that female-specific P450 2A5 is induced in the livers of TGF alpha transgenic male mice, particularly in liver tumors of transgenic male mice overexpressing TGF alpha, and may be useful as a marker for mouse hepatocarcinogenesis.