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The health-care system, homogenous ethnicity, and operative strategy for lower rectal cancer surgery in Japan are to some extent unique compared to those in Western countries. The National Clinical Database is a newly established nationwide, large-scale surgical database in Japan.To illuminate Japanese national standards of clinical care and provide a basis for efforts to optimize patient care, we used this database to construct a risk model for a common procedure in colorectal surgery-low anterior resection for lower rectal cancer.Data from the National Clinical Database on patients who underwent low anterior resection during 2011 were analyzed. Multiple logistic regression analyses were performed to generate predictive models of 30-day mortality and operative mortality. Receiver-operator characteristic curves were generated, and the concordance index was used to assess the model's discriminatory ability.During the study period, data from 16,695 patients who had undergone low anterior resection were collected. The mean age was 66.2 years and 64.5% were male; 1.1% required an emergency procedure. Raw 30-day mortality was 0.4% and operative mortality was 0.9%. The postoperative incidence of anastomotic leakage was 10.2%. The risk model showed the following variables to be independent risk factors for both 30-day and operative mortality: BMI greater than 30 kg/m, previous peripheral vascular disease, preoperative transfusions, and disseminated cancer. The concordance indices were 0.77 for operative mortality and 0.75 for 30-day mortality.The National Clinical Database is newly established and data entry depends on each hospital.This is the first report of risk stratification on low anterior resection, as representative of rectal surgery, with the use of the large-scale national surgical database that we have recently established in Japan. The resulting risk models for 30-day and operative mortality from rectal surgery may provide important insights into the delivery of health care for patients undergoing GI surgery worldwide.

Morphologically, liver metastases from colorectal carcinoma usually form as nodular tumor masses, whereas intraductal papillary growth in the bile duct is rare. A 65-year-old man underwent right hemicolectomy for advanced colon carcinoma, and histology of the primary carcinoma confirmed moderately differentiated adenocarcinoma with subserosal invasion, no vascular infiltration, and no lymph node metastasis. A liver tumor was found in the right paramedian Glisson pedicle and intraductal growth of cholangiocarcinoma was seen on imaging. We performed right hepatectomy and macroscopically, the resected specimen contained a growth in the bile duct lumen similar to cholangiocarcinoma. Histological examination revealed intraductal papillary proliferation of well-differentiated adenocarcinoma without vascular infiltration or lymph node metastasis in the hepatic hilum. Immunohistochemical staining revealed that the tumor cells were negative for cytokeratin-7 and positive for cytokeratin-20. Based on these findings, liver metastasis from colon carcinoma was diagnosed. Liver metastasis from colorectal carcinoma rarely arises as intraductal papillary growth in the bile duct, but the possibility of liver metastases with unusual morphology must be borne in mind for patients with a history of carcinoma in the digestive tract., Surgery Today, 41(2), pp.276-280; 2011

Background: A minilaparotomy approach is technically feasible for the resection of colorectal cancer in select patients. The aim of this study was to clarify the risk factors preventing the success of a minilaparotomy in the resection of colorectal cancer. Methods: Between April 2005 and August 2008, 141 consecutive patients were enrolled in this prospective study and scheduled to undergo resection of colorectal cancer using a minimal skin incision. The minilaparotomy involved a colorectal resection performed through a skin incision Results: A minilaparotomy was successful in 74 (52.5%) of 141 patients. Multivariate logistic regression analysis revealed that the failure of the minilaparotomy in the remaining 67 (47.5%) was independently related to gender (male), BMI (≥25.5), tumor location (splenic flexure and rectum), tumor adhesion/invasion on/into adjacent organs and the maximum tumor diameter (≥7.0 cm). Conclusion: Gender (male), BMI (≥25.5), tumor location (splenic flexure and rectum) and tumor aggressiveness [tumor adhesion/invasion on/into adjacent organs and maximum tumor diameter (≥7.0 cm)] were independent risk factors preventing the success of the minilaparotomy approach in the resection of colorectal cancer.

To clarify the relationship between morphological measurements of hepatic volume by computed tomography (CT-vol) and functional volume (RI-vol) by technetium-99m galactosyl human serum albumin (99mTc-GSA) scintigraphy, and its clinical significance, we examined 16 patients with a background liver status of either normal liver function (n = 4), chronic hepatitis or cirrhosis (n = 7), or obstructive jaundice (n = 5). In five patients who underwent preoperative portal vein embolization (PVE), volumetric measurement was performed 2 weeks after PVE. The mean values of CT-vol and RI-vol of the right lobe were 692± 147 cm3 (66.1 ± 10.7%) and 668 ± 159 cm3 (67.8 ± 13.2%), respectively, and those of the left lobe were 329 ± 138 cm3 (33.9 ± 10.6%) and 328± 170 cm3 (32.2 ± 13.2%), respectively. There were no significant differences in the volume measurements between the two volumetric techniques. Correlations between CT-vol and RI-vol in the right and left lobes were positive and significant (r = 0.912 and 0.903, respectively; both P′s < 0.001). The mean values of post-PVE CT-vol and RI-vol of the right lobe in five patients were significantly different (628 ± 149 and 456± 211 cm3, respectively; P = 0.033). However, the mean values of post-PVE CT-vol and RI-vol of the left lobe were not different (496 ± 124 and 483± 129 cm3, respectively). We propose that volumetric measurement by 99mTc-GSA scintigraphy is useful for detecting changes in functional volume of individual lobes of the liver and is a more dynamic method compared with detection of morphological changes by CT scan.

症例は45歳の男性で, 生体腎移植後12年経過していた. 腹痛で発症し, 白血球増多の進行のため腹部CTを行ったところ, 後腹膜気腫と腹腔内遊離ガスを認めた. 穿孔部位はS状結腸であり, ハルトマン手術を行った. 病理学的検査では憩室穿孔の疑いであった. 術前, シクロスポリン, ミゾリビン, メチルプレドニゾロンによる3剤併用免疫抑制療法を受けており, 術後早期も調節し続行した. 重篤な合併症は起こさず救命し, また移植腎機能も温存された. 腎移植後は拒絶反応抑制のため, 免疫抑制剤を使用しており免疫不全状態となっていることや, 副腎皮質ステロイドによる組織の脆弱性, 低腎機能による組織治癒能の低下など, 治療を行ううえで, 通常とは異なる病態がみられる. 本邦での腎移植後の大腸穿孔の報告は, 本例を含め12例あり, 生存9例 (うち移植腎機能喪失1例), 死亡2例であった. 男性・献腎移植例・S状結腸に多い傾向があった.

We describe a case of pseudomyxoma peritonei (PMP) successfully managed with intraperitoneal hyperthermic chemoperfusion. This case is unique due to the concurrent presence of intraductal papillary mucinous neoplasm (IPMN) of the pancreas. The patient presented with abdominal fullness. Abdominal computed tomography revealed massive ascites, thickened peritoneum, and a cystic lesion of the pancreas. Cytological examination of ascitic fluid sample showed mucin-rich atypical cells. Endoscopic retrograde pancreatography revealed a cystic lesion with the defect probably due to mural nodule and mucin, communicating with the pancreatic duct. At exploratory laparotomy, massive ascites and multiple nodules were identified within the peritoneal cavity. No primary tumour, including mucinous neoplasm of the appendix, was found. Histopathological examination of the omentum showed mucinous adenocarcinoma in pools of mucoid material, consistent with PMP. The relation between PMP and IPMN of the pancreas was possible, but not conclusive. The patient received intraperitoneal perfusion of saline heated to 42 degrees C containing cisplatin, etoposide, and mitomycin C, followed by 24 courses of postoperative chemotherapy with gemcitabine. The patient remains in good general condition with no signs of progression of PMP for 2 years, but with a gradual and progressive enlargement of the pancreatic cystic lesion.

We evaluated the efficiency of measuring hyaluronic acid (HA) levels preoperatively in patients with injured liver disease as a predictor of complications after hepatectomy.We examined patients who underwent hepatectomy for liver tumors secondary to chronic viral liver diseases or obstructive jaundice.The preoperative HA level correlated significantly with the indocyanine green retention rate at 15 min, liver activity at 15 min by technetium-99m galactosyl human serum albumin scientigraphy, and the histopathological activity index. It was also significantly elevated in patients with severe fibrosis caused by cirrhosis. After hepatectomy, the HA level was increased on postoperative day (PODS) 7, but had normalized by POD 28. The preoperative HA level tended to correlate with the regeneration rate on POD 28, and was significantly higher in patients with prolonged ascites or hepatic failure postoperatively. Multivariate analysis identified a serum HA level above 200 or 150 ng/ml as the only significant predictor of postoperative hepatic failure or long-term ascites, respectively (P0.05).Our findings indicate that the preoperative serum HA level is a good predictor of postoperative complications in patients who undergo hepatectomy for injured liver disease.

Dihydropyrimidine dehydrogenase (DPD) is the rate-limiting enzyme of 5-fluoropyrimidine (5-FU) catabolism. We examined whether tumor DPD expression is an effective marker in adjuvant therapy with oral fluoropyrimidines after curative resection of colorectal cancer.We studied 89 patients with stage II-III colorectal cancers who had undergone curative resections and received oral 5-FU-based adjuvant chemotherapy. The levels of DPD expression in tumor and normal colonic mucosa were measured by an enzyme-linked immunosorbent assay. In 53 tumor samples, DPD enzymatic activity was also analyzed in order to evaluate the relationship between DPD expression and enzymatic activity.DPD expression significantly correlated with DPD enzymatic activity in these 53 tumors ( r=0.56; P0.001). DPD expression in the tumors was significantly lower than in normal mucosa (47.1+/-30.8 and 56.4+/-18.5 U/mg protein, respectively; P0.05). We designated the cut-off value of tumor DPD as its median value (46.0 U/mg protein). Patients with low DPD expression had longer disease-free intervals than those with high DPD expression according to univariate analysis ( P=0.026). In a multivariate analysis, low DPD expression was significantly and independently associated with better survival.Tumor DPD expression is a useful marker for use with adjuvant chemotherapy with oral fluoropyrimidines after curative resection of colorectal cancer.

The clinical significance of and discrepancy between the indocyanine green retention rate at 15min (ICGR15) and liver activity at 15min (LHL15) by technetium-99m galactosyl human serum albumin ( [Formula: see text] -GSA) scintigraphy and clinical outcome were examined in 140 patients who underwent hepatectomy. Both ICGR15 and LHL15 were significantly associated with portal pressure and liver function tests, fibrotic degree and regeneration of the remnant liver ( [Formula: see text] ). The significance of the correlation between LHL15 and liver functions and HAI score appeared to be better than that with ICGR15. A significant correlation was observed between ICGR15 and LHL15 ( [Formula: see text] 0.591, [Formula: see text] ) for all but 12 patients (8.6%). Of three patients with LHL15 better than ICGR15, two had obstructive jaundice and one had an intrahepatic shunt. Patient outcome was relatively good. In nine patients with LHL15 worse than ICGR15, the HAI score was higher (=7) and six of the nine had hepatic failure or uncontrolled ascites. Complications were frequently observed in patients with LHL15 below 0.875 (80% versus 30%, [Formula: see text] ). Our results indicate that [Formula: see text] -GSA scintigraphy is a reliable auxiliary test of hepatic functional reserve combined with ICGR15 for selecting the extent of hepatectomy and predicting patient outcome.

The relationship between patient prognosis and various tumor biological factors has been reported previously, and prognostic factors of tumor biology may improve predictions of prognosis after hepatectomy for hepatocellular carcinoma (HCC) and may contribute to a new staging classification. This study was designed to provide an immunohistochemical analysis of tumor biological factors in patients who underwent hepatectomy for HCC. Factors analyzed included p53 overexpression, microvessel counts, proliferating cell nuclear antigen, and expression of nm23. We examined 81 HCCs from patients with chronic liver diseases. In patients who underwent chemoembolization before surgery, or those a who had confluent multinodular tumor, p53 expression tended to be higher than in patients without chemoembolization (33% vs 11%) or those with a simple nodular tumor (28% vs 10%), but the difference was not statistically significant (P = 0.051 and P = 0.092, respectively). A lower tumor microvessel count and negative nm23 expression were significantly associated with poor disease-free survival by univariate analysis (P ≪ 0.01 and P ≪ 0.05, respectively). A lower tumor microvessel count was found to be a significant prognostic factor for disease-free and overall survivals (risk ratios, 2.44 and 3.13, respectively; P ≪ 0.05), in addition to tumor size, vascular invasion, and longterm ascites, by Cox’s multivariate analysis. Tumor microvessel count appears to be a useful prognostic marker for predicting HCC recurrence and patient survival.

症例は急性進行性糸球体腎炎のためステロイド治療中の71歳の女性で, 下腹部痛のため緊急入院した. 体温38.8℃, 脈拍数115/分, 下腹部に筋性防御を認め, 白血球数1,900/mm3で, 腹部CTにより直腸穿孔と診断された. ハルトマン手術を行った後, 持続的血液濾過透析とレスピレーター管理により順調に経過していたが, 術後8日目に突然全身倦怠感を訴え, モニター上心室頻拍が出現した. リドカイン静注後の心電図でII, III, aVF, V2～V6と広範囲にST上昇がみられ, 心エコーでは心基部の過収縮と中部から心尖部にかけてのバルーン状拡張がみられ,“たこつぼ型心筋症” と診断された. 左室内圧較差は60～130mmHgで, これによる低心拍出が心室頻拍の原因になった可能性が示唆された. 心エコーを中心に厳重な経過観察を行ったところ, 発症2日目より徐々に壁運動の改善がみられ, 21日目には左室内圧較差も軽快した. 本症の原因として消化器外科手術は重要で, 消化器外科医にとって周知しておくべき術後合併症の1つである.

A minimally invasive surgical approach should be employed to resect symptomatic colonic lipomas whenever possible. We report two cases of large colonic lipomas that were successfully removed using a minimally invasive minilaparotomy approach. Patient 1 was a 53-year-old man with a 3.8-cm symptomatic submucosal lipoma in the ascending colon and patient 2 was a 57-year-old woman with a 4.2-cm symptomatic submucosal lipoma in the transverse colon. Both lipomas were successfully removed through a 5-7-cm minilaparotomy. Normal bowel function returned quickly without any postoperative complications. These case reports demonstrate that the minilaparotomy approach is a suitable alternative to conventional laparotomy to remove a large colonic lipoma.

This study compares surgical outcomes for local resection of rectal tumors by two approaches: (1) gasless, video-endoscopic transanal-rectal tumor excision (gasless VTEM); and (2) a conventional posterior approach. Gasless VTEM involves a modification of transanal endoscopic microsurgery (TEM) that incorporates a standard laparoscopic video camera without a CO(2) insufflation system. A series of 42 patients with 45 rectal tumors (9 adenomas, 36 adenocarcinomas) who underwent gasless VTEM between 1993 and 2000 were studied prospectively. The control group consisted of 26 similar patients who underwent conventional surgery (transsacral or transsphincteric approach) between 1985 and 1993. Age, gender ratio, tumor localization, maximum tumor diameter, and histology for the cases and the controls were similar, whereas operating time and blood loss were significantly greater in the control group (p < 0.001 and p < 0.001, respectively). The postoperative intervals until able to walk, urinary catheter removal, solid food intake, and discharge from hospital were significantly shorter in the gasless VTEM group (p < 0.001, p = 0.002, p < 0.001, and p < 0.001, respectively); analgesic requirements were significantly less (p < 0.001). There was no operative mortality in either group. Postoperative complications developed significantly less frequently in the gasless VTEM group than in the control group (7.1% vs. 38.5%; p = 0.003). During the median follow-up length of 73.3 months, no patient developed tumor recurrence in the gasless VTEM group, whereas one patient did in the control group. In conclusion, gasless VTEM is less invasive and allows shorter hospitalizations and reduced complications than the conventional posterior approach, thereby providing an attractive alternative for selected patients.

The present study was undertaken to evaluate p53 gene mutation as a prognostic factor in patients with colorectal cancer. Nonisotopic RNase cleavage assay (NIRCA), recently used for detecting gene mutations, was employed to detect p53 gene mutations in this study. In 15 samples of colorectal tumors, NIRCA was confirmed to be simple, accurate, and thus useful for clinical use, compared with polymerase chain reaction single-strand conformational polymorphism (PCR-SSCP). In another group of 79 cases of colorectal cancer analyzed for p53 gene mutation by using NIRCA, mutations were detected in 58 of 79 (73.4%) cases. Multivariate Cox proportional-hazards analysis showed that p53 gene mutation was a significant prognostic factor in patients with colorectal cancer. Our results showed that NIRCA is a simple and sensitive method, and thus useful for genetic screening of colorectal cancer. Furthermore, our results showed that p53 gene mutation is an independent predictor of poor prognosis in colorectal cancers.

This study was designed to provide a histopathological analysis focusing on fibrosis (staging) and necroinflammatory reaction (grading, hepatitis activity index: HAI) in noncancerous liver tissue, and mitotic index (MI) in cancerous liver tissue to predict prognosis in 81 patients with chronic hepatitis or cirrhosis who underwent hepatectomy for hepatocellular carcinoma (HCC). The incidence of grade 2/3 and higher HAI was higher in patients with viral hepatitis C. The incidence of grade 2/3 was associated with vascular invasion of HCC, postoperative liver dysfunction, and cancer recurrence. Higher MI (≥5) was significantly associated with vascular invasion, poor histological differentiation, and recurrence rate (P < 0.05). Multivariate analysis showed that higher grade was the factor strongly associated with cancer recurrence (odds ratio: 10.621, P = 0.006). Higher MI correlated with overall patient survival (P < 0.05) by univariate analysis. Grading and MI are the useful prognostic markers for predicting tumor recurrence and patient survival.

Macroscopic classification of metastatic liver tumors has been recommended to predict patient prognosis. Methods: We examined the morphological analysis of metastatic colorectal cancer in 64 patients who underwent hepatic resection and the relationship with clinicopathologic factors. To identify the irregularity of the tumor, we calculated three formulas: (1) actual area of representative cut surface of tumor/circular length of tumor margin, (2) actual area of representative cut surface of tumor/elliptic area, defined by the major and minor axes, and (3) deviation of radius of marginal curvature. Results: Following Yasui's macroscopic classification, the values of formulas (1) and (2) in confluent nodules were significantly lower than those in simple nodules (P < 0.05), while the value of formula (3) in confluent nodules was significantly greater than that in simple nodules (P < 0.05). Only a lower value of formula (1) (less than 0.19) was significantly associated with postoperative recurrence (P < 0.05) and a lower value tended to be associated with a shorter disease-free survival after hepatectomy, but not significantly (P = 0.09). However, most values were not associated with any clinicopathologic factors or postoperative survival. Conclusions: We conclude that differences in the morphological irregularity of liver tumors in metastatic colorectal cancer do not have clinical significance.

It remains unclear whether human T-cell lymphotropic virus type-I (HTLV-I) infection is associated with an increased risk of malignancies other than adult T-cell leukemia/lymphoma.The authors investigated the geographic distribution of the incidence of adult T-cell leukemia/lymphoma and other malignancies in Nagasaki Prefecture, Japan, where HTLV-I is endemic. The world age-standardized incidence rates of adult T-cell leukemia/lymphoma and five cancers of other sites were calculated in 15 areas, using the data from the Nagasaki Prefectural Cancer Registry (1985-97).The incidence of adult T-cell leukemia/lymphoma was found to be positively correlated with that of biliary tract cancer in men (person-years-weighted r = 0.49, P = 0.06) and liver cancer in women (r = 0.56, P = 0.03), but not with cancer of the stomach, lung or cervix uteri.The results may not support the hypothesis that HTLV-I infection is strongly associated with an increased risk of cancer of the stomach, lung or cervix uteri. The association between HTLV-I infection and cancer of the biliary tract and the possible interaction between hepatitis C virus and HTLV-I in the development of liver cancer should be evaluated by prospective cohort studies.

The feasibility and safety of a minilaparotomy approach to terminal ileal Crohn’s disease have not been fully elucidated. The purpose of this study was to compare early outcomes utilizing this technique as an alternative to conventional approaches. Nine patients with terminal ileal Crohn’s disease (but no complicating enteric fistulas) who underwent minilaparotomy between January 1998 and September 2000 were studied prospectively. The minilaparotomy approach entails a complete surgical procedure performed through a skin incision of less than 7 cm. Ten similar patients who underwent conventional laparotomy between January 1995 and December 1997 served as the control group. Age, gender, body weight, height, body mass index, number of prior laparotomies, operating times, operative blood loss, and types of operative procedure were similar for cases and controls. The length of the laparotomy incision in the minilaparotomy approach group was significantly shorter than that in the conventional approach group (median length 6.0 vs. 16.5 cm; p

Sialyl Lewis(a) (CA19-9) and sialyl Lewis(x) antigens (SLX) may play a role in tumor metastasis by serving as functional ligands in the cell adhesion system. The authors examined preoperative serum levels of CA19-9 and SLX in 218 patients who underwent resection for gastric cancer to determine their prognostic value. The patients were divided into two groups, termed the low and high antigen groups, based on a value selected as a diagnostic cutoff. Correlation between the antigen serum levels, various established clinicopathologic factors, and prognosis were studied by univariate and multivariate analysis. The disease-specific interval for high CA19-9 and SLX groups was significantly shorter than that of their respective low groups (p = 0.0024 and p < 0.0001, respectively). Patients with stage III/IV tumors who had high serum SLX levels had shorter disease-specific intervals than those with low serum levels (p = 0.0017). A Cox's regression analysis revealed a high serum SLX level as an independent factor for worse outcome. In addition, logistic regression analysis revealed that a high serum SLX level was an independent predictor for liver metastasis. In conclusion, an elevated preoperative serum SLX level was a predictor for poor outcome after resection for gastric cancer, whereas CA19-9 was not.

Immunohistochemically detected expression of sialyl Lewis(x) (Le(x)) antigen was analyzed in 101 stage 0-II gastric cancers to clarify its prognostic value after curative gastrectomy. Patients with a high-expression of sialyl Le(x) antigen within their tumors had shorter disease-specific intervals than those with negative- or low-expressing tumors (P

We examined the immunohistochemical expression of sialosyl-Tn antigen in the colorectal cancer tissues of 116 patients who underwent curative resection to determine the association between patient prognosis and the expression of sialosyl-Tn in two different tissues: carcinoma and transitional mucosa. Negative or positive expression of sialosyl-Tn in the carcinoma and transitional mucosal tissues were denoted as CA− or CA+ and TM− or TM+, respectively. Patients were classified into one of four groups: CA−/TM−, CA−/TM+, CA+/TM−, and CA+/TM+. CA−/TM− was observed in 13 patients and CA−/TM+, CA+/TM−, or CA+/TM+ was observed in 103 patients. The difference in five-year survival between the CA−/TM− group and all the other groups was statistically significant (P = 0.0457), and multivariate analysis showed that sialosyl-Tn expression in at least one of the two tissues was an independent prognostic factor. We conclude that the evaluation of sialosyl-Tn expression in carcinoma as well as transitional mucosa is useful for predicting survival in colorectal cancer patients.

To construct a risk model for total gastrectomy outcomes using a nationwide Internet-based database.Total gastrectomy is a very common procedure in Japan. This procedure is among the most invasive gastrointestinal procedures and is known to carry substantial surgical risks.The National Clinical Database was used to retrieve records on more than 1,200,000 surgical cases from 3500 hospitals in 2011. After data cleanup, 20,011 records from 1623 hospitals were analyzed for procedures performed between January 1, 2011, and December 31, 2011.The average patient age was 68.9 years; 73.7% were male. The overall morbidity was 26.2%, with a 30-day mortality rate of 0.9%, in-hospital mortality rate of 2.2%, and overall operative mortality rate of 2.3%. The odds ratios for 30-day mortality were as follows: ASA (American Society of Anesthesiologists) grade 4 or 5, 9.4; preoperative dialysis requirement, 3.9; and platelet count less than 50,000 per microliter, 3.1. The odds ratios for operative mortality were as follows: ASA grade 4 or 5, 5.2; disseminated cancer, 3.5; and alkaline phosphatase level of more than 600 IU/L, 3.1. The C-index of 30-day mortality and operative mortality was 0.811 (95% confidence interval [CI], 0.744-0.879) and 0.824 (95% CI, 0.781-0.866), respectively.We have performed the first reported risk stratification study for total gastrectomy, using a nationwide Internet-based database. The total gastrectomy outcomes in the nationwide population were satisfactory. The risk models that we have created will help improve the quality of surgical practice.

A 72-year-old woman with diabetes mellitus was admitted with fever and general fatigue. Blood biochemistry showed elevated hepatic and biliary enzyme levels, abdominal computed tomography showed multiple liver abscesses with portal and superior mesenteric vein thrombosis, and total colonoscopy revealed a submucosal bacterial abscess in the ascending colon. The abscesses were determined to be associated with Enterococcus faecalis infection. The patient was treated conservatively with antibiotics (meropenem) and anticoagulants (warfarin), which led to a gradual amelioration of symptoms and resolution of thrombosis.

Objective This study aimed to create a risk model of mortality associated with esophagectomy using a Japanese nationwide database. Methods A total of 5354 patients who underwent esophagectomy in 713 hospitals in 2011 were evaluated. Variables and definitions were virtually identical to those adopted by the American College of Surgeons National Surgical Quality Improvement Program. Results The mean patient age was 65.9 years, and 84.3% patients were male. The overall morbidity rate was 41.9%. Thirty-day and operative mortality rates after esophagectomy were 1.2% and 3.4%, respectively. Overall morbidity was significantly higher in the minimally invasive esophagectomy group than in the open esophagectomy group (44.3% vs 40.8%, P = 0.016). The odds ratios for 30-day mortality in patients who required preoperative assistance in activities of daily living (ADL), those with a history of smoking within 1 year before surgery, and those with weight loss more than 10% within 6 months before surgery were 4.2, 2.6, and 2.4, respectively. The odds ratios for operative mortality in patients who required preoperative assistance in ADL, those with metastasis/relapse, male patients, and those with chronic obstructive pulmonary disease were 4.7, 4.5, 2.3, and 2.1, respectively. Conclusions This study was the first, as per our knowledge, to perform risk stratification for esophagectomy using a Japanese nationwide database. The 30-day and operative mortality rates were relatively lower than those in previous reports. The risk models developed in this study may contribute toward improvements in quality control of procedures and creation of a novel scoring system.

Acute diffuse peritonitis (ADP) is an important surgical complication associated with high morbidity and mortality; however, the risk factors associated with a poor outcome have remained controversial. This study aimed in collecting integrated data using a web-based national database system to build a risk model for mortality after surgery for ADP. We included cases registered in the National Clinical Database in Japan. After data cleanup, 8,482 surgical cases of ADP from 1,285 hospitals treated between January 1 and December 31, 2011 were analyzed. The raw 30-day and surgical mortality rates were 9.0 and 14.1 %, respectively. The odds ratios (>2.0) for 30-day mortality were as follows: American Society of Anesthesiologists (ASA) class 3, 2.69; ASA class 4, 4.28; ASA class 5, 8.65; previous percutaneous coronary intervention (PCI), 2.05; previous surgery for peripheral vascular disease (PVD), 2.45 and disseminated cancer, 2.16. The odds ratios (>2.0) for surgical mortality were as follows: ASA class 3, 2.27; ASA class 4, 4.67; ASA class 5, 6.54, and disseminated cancer, 2.09. The C-indices of 30-day and surgical mortality were 0.851 and 0.852, respectively. This is the first report of risk stratification after surgery for ADP using a nationwide surgical database. This system could be useful to predict the outcome of surgery for ADP and for evaluations and benchmark performance studies.

Background and Aim: The serum hyaluronic acid (HA) concentrations reflect the degree of hepatic fibrosis and sinusoidal endothelial cell damage. The HA concentrations were examined to evaluate liver damage during the perioperative period of hepatectomy. Methods: The HA level of serum samples from 79 patients who underwent a hepatectomy was measured, and the results were compared to conventional liver function tests, the degree of fibrosis, liver regeneration and complications. Results: Hyaluronic acid concentrations correlated with the severe fibrosis or histological activity index, and also correlated with liver function tests including transaminase level, platelet counts, prothrombin time activity, indocyanine green retention rate at 15 min (ICG R15), liver activity at 15 min by technetium-99m galactosyl human serum albumin scintigraphy (LHL 15), and portal pressure. The HA level postoperatively correlated with liver function, especially with total bilirubin. Hyaluronic acid levels at day 28 postoperatively correlated with ICG R15 and LHL 15. The hyaluronic acid level before surgery and at day 28 postoperatively correlated with the regeneration of remnant liver in major hepatectomy. The HA levels were significantly higher in patients with hepatic failure or prolonged ascites. Conclusion: Our results indicate that the measurement of the HA level is useful for monitoring liver damage or predicting complications associated with liver surgery.

Objective: To compare early outcomes of the minilaparotomy approach to the resection of rectal cancer with those of conventional laparotomy. Design: Retrospective study. Setting: University hospital, Japan. Subjects: 18 patients who had complete resection through a minilaparotomy and 20 who had a conventional laparotomy served as the study and the control groups, respectively. Patients who were overweight or morbidly obese (body mass index &#83 25) were excluded from the study. Interventions: Complete resection through a skin incision less than 7 cm in length, or a conventional incision. Main outcome measures: Early postoperative outcomes. Results: Postoperative time intervals to standing, walking, passing flatus, and removal of the urinary catheter, and analgesic requirements were significantly less in the minilaparotomy group ( p = 0.007, p = 0.004, p = 0.02, p = 0.002, and p = 0.05, respectively). Conclusions: The minilaparotomy for complete resection of rectal cancer is less invasive than conventional...

Background: Aberrations in chromosome 17 are important in carcinogenesis. We recently reported that numerical aberrations in chromosome 17 were associated with tumor progression in gastric cancer. The aim of this study was to determine the biological characteristics of gastric tumor cells with chromosome 17 numerical aberrations. Methods: Gastric tumor sections (n = 105) and metastatic lymph nodes (n = 16) were stained simultaneously for PCNA (proliferating cell nuclear antigen) and chromosome 17 centromere. Cancers were classified as follows: Group 1: PCNA(+) and numerical chromosomal aberration(+); Group 2: PCNA(−) and numerical chromosomal aberration(+); Group 3: PCNA(+) and numerical chromosomal aberration(−); and Group 4: PCNA(−) and numerical chromosomal aberration(−). Results: The frequency of Group 1 cells correlated with lymphatic invasion (P < .0001), lymph node metastasis (P < .0001), and venous invasion (P < .01). The frequency of these cells in gastric lesions was lower than in metastatic lymph nodes (P < .01). Logistic regression analysis identified the depth of invasion followed by the frequency of Group 1 cells were two of the most significant independent factors that could predict lymph node metastasis and lymphatic invasion. Conclusions: The frequency of gastric tumor cells positive for PCNA and chromosome 17 numerical aberrations may be an indicator of the metastatic potential of gastric cancers.

Preoperative serum levels of sialyl Lewis(a) (CA 19-9), sialyl Lewis(x) (SLX), and sialyl Tn (STN) antigens in colorectal cancer patients were examined to establish predictive factors for serum levels of these antigens compared with carcinoembryonic antigen (CEA). A total of 308 patients who underwent resection for a colorectal cancer were divided into low and high antigen groups (higher or lower than a selected diagnostic-based cutoff value). The cutoff values were 37 U/ml for CA19-9, 38 U/ml for SLX, 45 U/ml for STN, and 2.5 ng/ml for CEA. The American Joint Committee on Cancer Classification and Stage grouping was used to classify the tumors. Statistical tests were conducted using univariate and multivariate logistic regression analyses. For CA19-9, 81 patients (26.3%) were assigned to the high antigen group: for SLX, 39 (12.7%); for STN, 33 (10.7%); and for CEA, 133 (43.2%). Multivariate logistic regression analysis revealed that predictive factors associated with high antigen levels were female sex (odds ratio [OR], 1.78 vs male sex), T4 (OR, 3.26 vs T1/T2), and M1 (OR, 3.35 vs M0) for CA19-9; M1 (OR, 6.40 vs M0) for SLX; mucinous carcinoma (OR, 8.45 vs well differentiated adenocarcinoma) and M1 (OR, 8.24 vs M0) for STN; and mucinous carcinoma (OR, 7.21 vs well differentiated adenocarcinoma), T3/T4 (OR, 3.84/4.18, respectively, vs T1/T2), and M1 (OR, 6.39 vs M0) for CEA. In conclusion, high serum levels of CA19-9, SLX, and STN are strongly associated with distant metastasis. In addition, high serum levels of CA19-9 may be an independent predictor for female gender and T4, and high serum levels of STN may be an independent predictor for mucinous carcinoma.

The present study was designed to provide a systemic analysis of prognosis in 62 patients who underwent hepatic resection for colorectal liver metastasis. The analyzed factors included microvessel counts stained by CD34 and expression of two adhesion molecules, E-cadherin and CD44 variant exon 6-(v6) in these tumors. No significant factors related to recurrence were identified and only negative expression of CD44v6 tended to correlate with recurrence (P = 0.075). A short disease-free period to recurrence was noted in patients with high CEA levels (>10 ng/ml) and H2/3 classification. A short surgical margin, H2/3 classification, high microvessel counts (>60/field, ×200), and negative expression of CD44v6 and E-cadherin tended to be associated with poor prognosis. A high microvessel count was the most significant prognostic factor by multivariate Cox proportional hazards regression model. Hepatic resection without tumor exposure and a careful follow-up in cases identified with poor prognostic factors are necessary.

The serum levels of sialyl Lewisa (CA19-9), sialyl Lewisx (SLX), sialyl Tn (STN) and carcinoembryonic antigen (CEA) in peripheral venous blood and tumor drainage venous blood of

To investigate colorectal cancer-related carbohydrate antigen release and distribution, we evaluated serum levels of sialyl Le(a) (CA19-9) and sialyl Le(x) antigen (SLX) in blood samples obtained from both a peripheral vein and a tumor's draining vein.Blood samples were obtained during surgery from 126 patients. Based on these samples, patients were placed into a high-antigen group, with a concentration above a selected cutoff value, or into a low-antigen group, with a tumor marker concentration below that same value. The blood samples obtained from peripheral veins were designated by the "p" prefix, and samples from drainage veins were designated by the "d."Serum d-SLX levels were significantly higher than p-SLX levels (P.0001), although there was no difference between those of d-CA19-9 and p-CA19-9. Only 1 (3.6%) of 28 patients in the high d-CA19-9 group had a low p-CA19-9. In contrast, 6 (33.3%) of 18 patients in the high d-SLX group had low p-SLX levels (P = .0103). Correlations between pathological variables and either p-CA19-9 levels or d-CA19-9 levels were similar. However, both distant metastasis and venous invasion did prove to be independent variables related to d-SLX levels, as shown by logistic regression analysis.SLX may drain predominantly via the draining veins of colorectal tumors into portal circulation, whereas CA19-9 may drain via another route.

Colorectal tumors can be classified based on their growth pattern into the polypoid growth type (PG-type) and nonpolypoid growth type (NPG-type). We examined sialyl Tn antigen expression in advanced colorectal carcinomas that were classified as PG-type and NPG-type cancers in order to ascertain whether or not such expression correlates with other biologically and clinically important differences. A total of 94 advanced colorectal carcinomas were examined for sialyl Tn antigen expression, which was immunohistochemically detected by the monoclonal antibody TKH2. Univariate and multivariate analyses using logistic regression models were performed. Forty carcinomas (42.6%) were negative and 54 (57.5%) were positive for sialyl Tn antigen. Eighteen carcinomas (19.2%) were of PG type and 76 (80.8%) of NPG type. NPG-type cancers had a higher proportion of positive lymph node metastasis than PG-type cancers. Furthermore, sialyl Tn antigen was less often detected in NPG-type cancers (39 of 76; 51.3%) than in PG-type cancers (15 of 18; 83.3%; p = 0.0167). Multivariate analysis showed that two variables, lymph node metastasis and sialyl Tn antigen expression in carcinoma, were independently related to tumor growth patterns, that is NPG type and PG type. These data suggest that the difference in sialyl Tn antigen expression between two kinds of tumor growth patterns of advanced colorectal carcinomas, PG type and NPG type, may reflect different biological behaviors during tumor progression.

Sialyl-Tn (STn) antigen is a cancer-associated carbohydrate antigen expressed in cancers of the digestive tract. In the present study, we compared the serum level of STn antigen in 14 patients with benign diseases of the biliary tract and pancreas, 15 patients with bile duct cancers, and 9 patients with cancer of the pancreas. High levels of serum STn (>45 U/ml) were frequently detected in patients with carcinoma of the biliary tract (53.3%) or pancreas (55.6%), compared with the detection of high levels in those with benign diseases (14.3%; P < 0.05). Serum levels of STn did not correlate with the presence of jaundice, cholangitis, or pancreatitis, or with the level of carcinoembryonic antigen (CEA) or carbohydrate antigen (CA) 19-9. In cancer tissues, the expression of STn antigen detected by immunostaining correlated significantly with serum STn (P < 0.05). Our results indicate that measurement of serum STn level may be potentially useful for the diagnosis of carcinomas of the biliary tract and pancreas, particularly when combined with other tumor markers such as CEA or CA19-9.

Background: Adhesion molecules are closely involved in the development and growth of metastatic tumours. Methods: We examined the expression of two adhesion molecules in liver metastatic tumours originating from colorectal carcinomas and correlated the expression of E-cadherin (EC) and CD44 variant exon 6 (v6) in these tumours with prognosis after hepatic resection. We examined 39 primary colorectal and 44 liver metastatic tumours obtained from 39 patients and 30 non-metastatic colorectal carcinomas as controls. The expression of EC in primary colorectal carcinomas of the metastasis group was significantly lower than in the non-metastasis group (P < 0.05). The expression of EC was low in metastatic liver tumours. Results: The expression of CD44v6 in primary colorectal carcinomas of the metastasis group was significantly higher than in the non-metastasis group (P < 0.01). Expression of CD44v6 was high in metastatic liver tumours. However, there was no correlation between the expression of EC and CD44v6 or between each of these molecules and clinicopathological features of primary and metastatic tumours. Negative expression of EC and CD44v6 was a poor prognostic factor for survival after hepatic resection. Conclusions: Our results indicate that the lack of expression of EC and CD44v6 in liver metastases of colorectal cancer is associated with poor survival after surgery. © 1999 Blackwell Science Asia Pty Ltd

To clarify the relationship between multidrug resistance protein (MRP) and clinicopathologic features, the influence of adjuvant chemotherapy, and prognosis of patients who underwent resection of metastatic liver carcinomas originating from colorectal carcinomas, we examined the expression of MRP in tumor tissues by immunostaining. Specimens of 38 primary colorectal tumors and 44 metastatic liver tumors of colorectal origin were examined (metastatic group). We also examined 28 nonmetastatic colorectal carcinomas. The percentages of nonmetastatic tumors and of primary and metastatic tumors of the metastasis group that expressed MRP were similar. MRP expression in primary and metastatic tumors did not correlate with any clinicopathologic features. The use of adjuvant chemotherapy after operation for primary colorectal carcinomas was associated with increased MRP expression among metastatic liver tumors. Expression of MRP in the tumor did not influence the prognosis or survival rate after resection of primary or metastatic tumors. Our data suggest that MRP expression in metachronous liver metastases from colorectal carcinomas may be induced by administration of anticancer drugs but is not associated with clinicopathologic features of the tumor, liver metastasis, or prognosis.

In this study, we determined the proliferation indices of liver metastatic tumours originating from colorectal carcinomas using Ki67 and argyrophil nucleolar organizer region associated proteins (AgNOR) stain. We examined the primary and metastatic tumours in 27 patients with liver metastasis and eight cases with non-metastatic colorectal carcinoma as a control. The number of AgNOR dots in metastatic tumours was significantly higher than in the respective primary tumours of the metastasis group or in non-metastatic colorectal carcinomas. The Ki67 labelling index was similar in all groups. The Ki67 labelling index and AgNOR counts did not correlate with each other. There was no significant relationship between proliferation indices and the duration of the disease-free period following hepatic resection for metastases or with prognosis after hepatectomy. We conclude that Ki67 and AgNOR are not useful indicators of prognosis in patients who undergo operation for liver metastasis of colorectal carcinomas.

The expression of blood group antigens A, B, and H, as well as sialylated and nonsialylated forms of Lewis(a) and Lewis(x), was studied using immunohistochemical methods in normal and tumor tissues in the following cohort of patients: 51 patients with primary breast carcinoma, 13 with metastatic lymph node lesions, and 16 with benign tumors of the breast. As a control, normal tissue was obtained from a similar group of 22 patients with breast cancer. The noncancerous tissues expressed the same A/B/H antigens as the patients' red blood cells and also usually expressed Lewis-related antigens. Seventy-six percent of primary carcinomas failed to express the appropriate A/B/H antigens, and in one blood group A patient the tumor tissue expressed B antigen. In the metastatic lesions, Lewis(a)/sialyl Lewis(a) expression was reduced when compared with the primary tumors, but Lewis(x)/sialyl Lewis(x) antigens were still expressed. These results suggest a possible relationship between the metastatic behavior of the tumor and expression of the blood group antigens.

The incidence of non-familial multiple primary cancer in colorectal cancer patients has increased in recent years in Japan. To clarify the characteristic genetic aberrations in such multiple cancers, we examined structural chromosomal aberrations by fluorescence in situ hybridization, using chromosome 17-specific and p53 cosmid DNA probes. We established short-term cultures of 78 surgical specimens and were able to obtain observable metaphase spreads in 23 single colorectal cancer specimens and in 6 colorectal cancer specimens from patients with double primary cancers. The frequency of chromosome 17 and/or p53 locus translocation was significantly greater in tumors with double cancer than in single colorectal cancers (P < 0.05 and P < 0.01, respectively). These aberrations in double cancers frequently appeared even at an early Dukes' stage (A and B) of colorectal carcinoma. Our results suggest that translocation of chromosome 17 and the p53 locus may be specific genetic events probably associated with carcinogenesis of multiple primary cancers in colorectal cancer.

Numerical aberrations of chromosome 17 and nuclear DNA content were compared in patients with hereditary non-polyposis colorectal cancer (HNPCC) and those with sporadic colorectal cancer (SCRC). During a period of 22 years, 30 cases (3.2%) from 28 families satisfied the Japanese clinical criteria of HNPCC. Using freshly frozen tissue samples, we investigated chromosomal aberration with fluorescence in situ hybridization with alpha satellite DNA probe for chromosome 17. Flow cytometric quantification of nuclear DNA content showed DNA aneuploidy in 9 of 15 patients (60.0%) with HNPCC and in 160 of 234 patients (68.4%) with SCRC; there was no significant difference between HNPCC and SCRC. The mean proportion of nuclei with aneusomy 17 (numerical chromosome aberration index; NCAI) in 14 patients with HNPCC was significantly higher than that in 42 patients with SCRC (46.8 ± 5.0% vs 39.0 ± 10.3%, P < 0.01). NCAI increased in proportion with the progression of the disease in SCRC (26.1% in stage I, 33.3% in stage II, 38.8% in stage IIIa, 42.7% in stage IIIb, and 46.2% in stage IV, P < 0.01), whereas NCAI in HNPCC was high in all stages (43.5%–49.2%). The proportion of patients with multiple numerical aberration of chromosome 17 was significantly higher in HNPCC (9/14) than among SCRC (11/42). Our data suggest that chromosome 17 is present in an unstable condition in HNPCC.

We examined the expression of vascularendothelial growth factor (VEGF) and microvessel countsexpressed by CD34 staining in 39 patients with primaryand 44 patients with metastatic liver tumors ofmetastatic colorectal carcinoma, and 29 patients withnonmetastatic colorectal carcinoma as control in orderto determine their value in the evaluation of prognosisand recurrence after hepatectomy. Microvessel counts in primary colorectal carcinomas of themetastatic group were significantly higher than those incontrol (P < 0.05). Neither factor correlated withany clinicopathological feature of primary or metastatic liver carcinomas. Higher microvessel counts inmetastatic liver tumors tended to be associated with ashorter disease-free interval to second recurrence inthe remaining liver (P = 0.069) and were significantly associated with poor prognosis afterhepatectomy (P < 0.05). We conclude that microvesselcount is an important marker of liver metastatasis andprognosis in patients with colorectal carcinoma treated with hepatectomy.

To characterize the numerical chromosome aberrations in gallbladder neoplasms, we examined surgically resected tissues using fluorescence in situ hybridization. The aberrations in 15 specimens of adenocarcinomas and 2 adenomas were compared with those in 4 samples of adenomyomatosis and 17 samples of normal epithelium. We calculated the frequency of aneusomy and determined the chromosome indexes (mean number of chromosomes per nucleus) of chromosomes 17 and 18. The pattern of DNA ploidy was analyzed by flow cytometry. In normal epithelium, adenomyomatosis and adenomas, DNA aneuploidy was not observed, while 13 (87%) carcinomas showed DNA aneuploidy, including 2 specimens with multiploidy. No numerical aberrations were observed in normal epithelium and adenomyomatosis. A numerical gain of chromosome 17 was observed in a single adenoma and in 10 (66%) carcinomas. A numerical gain of chromosome 18 was observed in 6 (40%) carcinomas, but not in other tissues. The chromosome index of chromosome 17 was significantly higher in adenomas and carcinomas (2.45±0.60 and 2.29±0.14, respectively) compared with normal epithelium. Our cytogenetic findings did not correlate with any histopathologic features of carcinomas. Our results indicated that the gains of chromosome 17 and 18 represented early chromosomal alterations in gallbladder neoplasms and were maintained in advanced carcinomas.

To investigate the characteristics of the numerical chromosome aberrations in liver metastasis of colorectal cancers, fluorescence in situ hybridization (FISH) for chromosomes 8, 18, 14/22, and 20 was performed in 18 specimens of primary regions and 18 of metastatic regions in liver metastasis of colorectal cancers compared with 15 of non-liver metastatic cancers. Among these numerical aberrations, the gain of chromosome 20, especially copy numbers exceeding three, was frequently observed in primary and metastatic cancers. Among these numerical aberrations, the gain of chromosome 20, especially copy numbers exceeding three, was frequently observed in primary and metastatic regions of liver metastasis groups compared with that of the non-liver metastasis group (P < 0.05). The incidences of gain of chromosome 20 in both regions of the liver metastasis group were higher than that of the non-liver metastasis group (P < 0.05). The gain of chromosome 20 is a frequent aberration in primary and metastatic regions in patients with liver metastatic colorectal cancers and may be available as a genetic marker for the diagnosis or prediction of liver metastasis.

To create a mortality risk model after pancreaticoduodenectomy (PD) using a Web-based national database system.PD is a major gastroenterological surgery with relatively high mortality. Many studies have reported factors to analyze short-term outcomes.After initiation of National Clinical Database, approximately 1.2 million surgical cases from more than 3500 Japanese hospitals were collected through a Web-based data entry system. After data cleanup, 8575 PD patients (mean age, 68.2 years) recorded in 2011 from 1167 hospitals were analyzed using variables and definitions almost identical to those of American College of Surgeons-National Surgical Quality Improvement Program.The 30-day postoperative and in-hospital mortality rates were 1.2% and 2.8% (103 and 239 patients), respectively. Thirteen significant risk factors for in-hospital mortality were identified: age, respiratory distress, activities of daily living within 30 days before surgery, angina, weight loss of more than 10%, American Society of Anesthesiologists class of greater than 3, Brinkman index of more than 400, body mass index of more than 25 kg/m, white blood cell count of more than 11,000 cells per microliter, platelet count of less than 120,000 per microliter, prothrombin time/international normalized ratio of more than 1.1, activated partial thromboplastin time of more than 40 seconds, and serum creatinine levels of more than 3.0 mg/dL. Five variables, including male sex, emergency surgery, chronic obstructive pulmonary disease, bleeding disorders, and serum urea nitrogen levels of less than 8.0 mg/dL, were independent variables in the 30-day mortality group. The overall PD complication rate was 40.0%. Grade B and C pancreatic fistulas in the International Study Group on Pancreatic Fistula occurred in 13.2% cases. The 30-day and in-hospital mortality rates for pancreatic cancer were significantly lower than those for nonpancreatic cancer.We conducted the reported risk stratification study for PD using a nationwide surgical database. PD outcomes in the national population were satisfactory, and the risk model could help improve surgical practice quality.

Right hemicolectomy is a very common procedure throughout the world, although this procedure is known to carry substantial surgical risks. The present study aimed to develop a risk model for right hemicolectomy outcomes based on a nationwide internet-based database. The National Clinical Database (NCD) collected records on over 1,200,000 surgical cases from 3,500 Japanese hospitals in 2011. After data cleanup, we analyzed 19,070 records regarding right hemicolectomy performed between January 2011 and December 2011. The 30-day and operative mortality rates were 1.1 and 2.3 %, respectively. The 30-day mortality rates of patients after elective and emergency surgery were 0.7 and 6.0 %, respectively (P