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Vasohibin-1 (VASH1) is an angiogenesis inhibitor, while vasohibin-2 (VASH2) is a proangiogenic factor. The roles of VASH1 and VASH2 expression in gastroenterological cancers remain unclear. We searched for relevant literature, specifically studies on gastroenterological cancer, and evaluated the relationship between VASH expression and clinical outcomes. Nine studies on VASH1 involving 1,574 patients were included. VASH1 expression was associated with the TNM stage [OR (odds ratio) 2.05, 95% CI (confidence interval) 1.24-3.40], lymph node metastasis (OR 1.79, 95% CI 1.24-2.58), lymphatic invasion (OR 1.95, 95% CI 1.41-2.68), and venous invasion (OR 2.49, 95% CI 1.60-3.88); poor clinical outcomes were associated with high VASH1 expression. High VASH1 expression was associated with a significantly shorter overall survival (OS) [HR (hazard ratio) 1.69, 95% CI 1.25-2.29] and disease-free survival (DFS) (HR 2.01, 95% CI 1.28-3.15). Three studies on VASH2 involving 469 patients were analyzed. VASH2 expression was associated with the TNM stage (OR 4.21, 95% CI 1.89-9.51) and venous invasion (OR 2.10, 95% CI 1.15-3.84); poor clinical outcomes were associated with high VASH2 expression. High VASH2 expression was associated with a significantly lower OS (HR 1.61, 95% CI 1.09-2.37). In conclusion, high VASH1 and VASH2 expression levels were associated with poor clinical outcomes and prognosis in patients with gastroenterological cancers.

Background A gastrointestinal stromal tumor rupture entails a high risk of recurrence even after curative surgery. However, the definition of rupture is unclear, and the question of whether patients with a minor rupture should be treated with adjuvant imatinib remains controversial. Methods The present, retrospective, multicentric study enrolled 57 patients with gastrointestinal stromal tumor with a minor/major tumor rupture, of whom 46 were finally found to be eligible for analysis. Tumor ruptures were subclassified by their degree, timing and cause. Multivariate analysis was performed to identify the risk factors of all types of recurrence as well as of peritoneal recurrence only. Results The study cohort included minor (n = 24), intraoperative (n = 19) and iatrogenic (n = 20) ruptures besides the typical types (major, preoperative and spontaneous). All intraoperative ruptures were iatrogenic. In total, 27 patients (58.7%) had a recurrence in the peritoneum (n = 17) and/or the liver (n = 13) during a median follow-up period of 5.8 years, but no recurrence was observed in patients with tumor rupture as a single, high-risk factor. Multivariate analysis found the timing of tumor rupture to be an independent risk factor of poor recurrence-free survival (hazard ratio: 2.37; 95% confidence interval: 1.02–5.49; P = 0.045). Conclusions Preoperative tumor rupture in patients with a ruptured gastrointestinal stromal tumor was associated with poor recurrence-free survival. Our results suggested that a distinction should be made between preoperative and intraoperative tumor ruptures when considering the indications for adjuvant imatinib therapy for gastrointestinal stromal tumor patients with tumor rupture as a single, high-risk factor of recurrence.

Esophageal cancer is the seventh most common malignancy and sixth most common cause of cancer-related death globally. Esophageal squamous cell carcinoma (ESCC) with aortic or tracheal invasion is considered unresectable, and has an extremely poor prognosis; its standard treatment is definitive chemoradiotherapy (dCRT). In recent years, induction chemotherapy (ICT) has been reported to yield high response rates for locally advanced ESCC, and the efficacy and safety of ICT followed by conversion surgery (CS) have been investigated. Multimodal treatment, combining surgery with induction chemoradiotherapy (ICRT) or ICT, is necessary to improve ESCC prognosis. CS is generally performed for locally advanced ECC after ICRT or ICT when tumor downstaging is achieved, although its prognostic benefit remains controversial. The Japan Clinical Oncology Group (JCOG) has conducted a three-arm phase III randomized controlled trial (JCOG1510) to confirm the superiority of DCF (docetaxel, cisplatin, and 5-fluorouracil) ICT, over conventional dCRT, among patients with initially unresectable ESCC. In recent years, researchers have reported favorable outcomes of induction therapy followed by CS and salvage surgery, after dCRT or systemic immunochemotherapy. In this review, we will describe the latest developments in the multimodal treatment including chemotherapy, CRT, surgery, and immunotherapy, which may improve oncological and survival outcomes for patients with cT4 ESCC.

Background Intestinal knot formation, in which two segments of the intestine become knotted together, can result in intestinal obstruction. An ileo-ileal knot refers to knot formation between two ileal segments and is a very rare benign disease. We report a case of strangulated bowel obstruction caused by true ileo-ileal knot formation. Case presentation An 89-year-old woman was referred to our hospital with the diagnosis of intestinal obstruction. Contrast-enhanced computed tomography revealed the small bowel forming a closed loop, with poor contrast effect. Based on the findings, the patient was diagnosed as having strangulated bowel obstruction, and emergency surgery was performed. At laparotomy, two segments of the ileum were found to be tied together forming a knot, and both segments were necrotic. Although it was necessary to release the strangulated small bowel, we did not immediately release the knot, but first proceeded with ligation of the mesenteric vessels to the strangulated small bowel to prevent dissemination of toxic substances from the necrotic bowel into the systemic circulation. The surgery was completed with resection of the necrotic ileum and anastomosis of the small intestine. The postoperative course was uneventful, and the patient was discharged home. Conclusion We encountered a case of strangulated bowel obstruction caused by true ileo-ileal knot formation. Resection of the necrotic small intestine without releasing the knot could be performed safely, and might be considered as an option of surgical procedure.

This prospective multicenter non-randomized phase III study aims to evaluate the long-term outcome of sentinel node navigation surgery for early gastric cancer compared with conventional distal or total gastrectomy. Clinically diagnosed primary T1N0M0 gastric cancer patients with a single lesion (≤40 mm) and without previous endoscopic treatment will be enrolled in this study. Sentinel nodes are identified by dye and radioisotope tracers and are subjected to intraoperative rapid pathology. For patients with negative sentinel node metastasis, individualized surgery consisting of limited stomach resection and sentinel node basin dissection is performed, while standard gastrectomy with D2 lymph node dissection is employed for the positive sentinel node patients. A total of 225 patients will be accrued from 13 hospitals that have experience in sentinel node mapping. The primary endpoint is 5-year relapse-free survival. The secondary endpoints are overall survival, sentinel node detection rate, diagnostic accuracy for sentinel node, distribution of sentinel nodes and metastatic sentinel node/non-sentinel node, and postoperative quality of life.

Purpose This study compared the pros and cons of two post-distal gastrectomy (DG) reconstruction methods by comparing the patient quality of life and functional dynamics at one year postoperatively. Methods We compared functional outcomes between Billroth I following laparoscopic 1/2 DG (L-B1; n = 27) and Roux en Y following laparoscopic 4/5 DG (L-RY; n = 24), including laparoscopic total gastrectomy (L-TG; n = 25), at one year postoperatively. Clinical investigations were performed in each patient, and functional evaluations by the acetaminophen (AAP) absorption test and plasma gastrointestinal hormone measurements were performed in consenting patients in each group (L-B1: n = 10, L-RY: n = 10, L-TG: n = 5). Results Postoperative/preoperative body weight ratios were significantly higher in the L-B1 and L-RY groups, in descending order than the L-TG group, although the meal intake ratio was not significantly different between the L-B1 and L-RY groups. The incidence of remnant gastritis was significantly higher in the B1 than in the RY group. AAP levels, glucose and glucagon-like peptide 1 were significantly lower in the L-B1 than in the L-RY group. Active ghrelin levels (AGL) were similar between the L-B1 and L-RY groups. Conclusions L-B1 maintains gradual intestinal absorption and physiological meal passage and prevents postoperative weight loss. L-RY results in maintenance of the postoperative meal intake via high AGL, equivalent to that in the L-B1 group.

Background/Aim: In the Japanese Classification of Gastric Carcinoma, T4a gastric cancer is defined as tumor invasion contiguous to the serosa or penetrating the serosa with exposure to the peritoneal cavity. The aim of this study was to assess the impact of T4a subclassification of gastric cancer on survival. Patients and Methods: A total of 326 patients with T4a cancer who had undergone gastrectomy were enrolled. The T4a tumors were classified into two groups: serosa-contiguous or serosa-exposed. Results: The serosa-exposed group had a significantly worse prognosis, and multivariate analysis identified the T4a subclass as an independent prognostic factor. Analysis of the risk factors for recurrence identified the T4a subclass as a significant risk factor for peritoneal recurrence in patients undergoing curative gastrectomy. Conclusion: The serosa-contiguous and serosa-exposed subgroups of T4a gastric cancer showed different biological behaviors. These groups may need to be treated as separate.

Background/Aim: Several studies have investigated prognostic factors in patients with T2 gastric cancer, but no consensus has been reached to date. The aim was to investigate the clinicopathological significance of the status of tumor invasion into the muscularis propria (MP) in T2 gastric cancer patients. Patients and Methods: A total of 113 patients with T2 cancer were enrolled. The status of caner invasion was analyzed according to width (extent of horizontal invasion) and depth (extent of vertical invasion). Results: The prognosis of the group with wide width of invasion (≥1.5 cm) was significantly poorer than that of the group with narrow width of invasion (

Background Angiodysplasia of the gastrointestinal tract is a rare vascular pathology that sometimes causes massive hemorrhage. Angiodysplasias are particularly difficult to find in the small intestine for anatomical reasons, often impeding their diagnosis and treatment. Lesion localization is a major challenge in cases of small bowel bleeding requiring surgical intervention. Case presentation The present case was a 52-year-old woman who was urgently hospitalized with repeated tarry stools. Surgical intervention was chosen after conservative treatment failed to improve her condition. The source of bleeding was suspected to be a vascular lesion discovered in the small intestine during a past double-balloon endoscopy. Abdominal contrast computed tomography revealed a jejunal hemorrhage. We chose selective arterial embolization to stabilize her hemodynamics followed by surgical intervention as her treatment plan. Several embolic and contrast agents (cyanoacrylate, indigo carmine, and Lipiodol) were combined to help identify the location of the lesion during surgery. This multi-pronged approach allowed us to localize the lesion under laparoscopic guidance with high confidence and accuracy, and to excise a 6-cm segment of the small intestine. The lesion was histologically diagnosed as angiodysplasia. No re-bleeding has been observed since the operation. Conclusion We report our experience with a case of jejunal angiodysplasia, which was localized with selective arterial embolization using an array of embolic and contrast agents, and then excised laparoscopically. Selective arterial embolization with indigo carmine dye to treat small bowel bleeding preoperatively not only makes the surgery safer by stabilizing the patient’s hemodynamics, but is also very useful for localizing the lesion intraoperatively.

Purpose Functional outcomes were prospectively compared between two types of reconstruction [double tract (L-DT; n = 15) and jejunal interposition (L-JIP; n = 15)] following laparoscopic half-proximal gastrectomy (LPG), including laparoscopic total gastrectomy (L-TG; n = 30) as a control group, at 1 year after surgery. Methods Clinical investigations were performed in each patient, and functional evaluations, involving the swallowing of an alimentary liquid containing acetaminophen (AAP), followed by measurements of the concentrations of AAP and hormones in the sitting (n = 5) and in the supine positions (n = 5), were carried out in each group. Results The post-/preoperative body weight ratios were significantly higher in the L-DT and L-JIP groups than in the L-TG group. The AAP levels were significantly lower in the LPG group than in the LTG group. The AAP, insulin, and gastrin levels in the L-JIP group were markedly increased in the sitting position compared with the supine position, while those in the L-DT and L-TG groups were stable in both positions. Conclusions L-JIP and L-DT are procedures that maintain gradual intestinal absorption and help improve the quality of life. Intestinal absorption and hormonal secretion were relatively unaffected by the posture of the meal intake after L-DT, so L-DT might be the procedure providing the most stable results.

The incidence of Helicobacter pylori-negative gastric cancer is very low. A 60-year-old man was referred to Tokai University Hospital from a local clinic because of eosinophilia. The laboratory data revealed prominent eosinophilia, with a white blood cell count of 7,900 /μL and increased eosinophil granulocyte level of 1,659 /μL. After an examination for secondary eosinophilia, esophagogastroduodenoscopy showed an enlarged gastric fold in the corpus, suggesting type 4 gastric cancer. Repeated esophagogastroduodenoscopy (EGD) and a re-biopsy demonstrated poorly differentiated adenocarcinoma and signet ring cell carcinoma. The patient was negative for Helicobacter pylori infection according to the serum anti-Helicobacter pylori antibody, culture and histopathological findings.

Background: Gastrointestinal stromal tumours (GISTs) with high-risk features have poor prognosis even if adjuvant treatment is given. Neoadjuvant imatinib may increase the cure rate by shrinking large GISTs and preserve organ function. Methods: We conducted an Asian multinational phase II study for patients with gastric GISTs ≥10 cm. Patients received neoadjuvant imatinib (400 mg/day) for 6–9 months. The primary end point was R0 resection rate. Results: A total of 56 patients were enroled in this study. In the full analysis set of 53 patients, neoadjuvant imatinib for ≥6 months was completed in 46 patients. Grade 3–4 neutropenia and rash occurred in 8% and 9%, respectively, but there were no treatment-related deaths. The response rate by RECIST was 62% (95% CI, 48–75%). The R0 resection rate was 91% (48/53) (95% CI, 79–97%). Preservation of at least half of the stomach was achieved in 42 of 48 patients with R0 resection. At the median follow-up time of 32 months, 2-year overall and progression-free survival rates were 98% and 89%, respectively. Conclusions: Neoadjuvant imatinib treatment for 6–9 months is a promising treatment for large gastric GISTs, allowing a high R0 resection rate with acceptable toxicity.

A 45-year-old woman was found to have a pancreatic tumor by abdominal ultrasound performed for a medical check-up. Abdominal contrast-enhanced computed tomography showed a hypovascular tumor measuring 30 mm in diameter in the pancreatic tail. Endoscopic ultrasound-guided fine needle aspiration was performed. An extragastric growing gastrointestinal stromal tumor was thereby diagnosed preoperatively, and surgical resection was planned. Laparoscopic surgery was attempted but conversion to open surgery was necessitated by extensive adhesions, and distal pancreatectomy, splenectomy, and partial gastrectomy were performed. The histological diagnosis was an intra-abdominal desmoid tumor. A desmoid tumor is a fibrous soft tissue tumor arising in the fascia and musculoaponeurotic tissues. It usually occurs in the extremities and abdominal wall, and only rarely in the abdominal cavity. We experienced a case with an intra-abdominal desmoid tumor that was histologically diagnosed after laparotomy, which had been preoperatively diagnosed as an extragastric growing gastrointestinal stromal tumor. Although rare, desmoid tumors should be considered in the differential diagnosis of intra-abdominal tumors. Herein, we report this case with a literature review.

Background: The aim of this study was to clarify the impact of the horizontal width of tumor invasion into the subserosal layer on prognosis in patients with T3N0 gastric cancer. Patients and Methods: A total of 72 patients with T3N0 cancer were enrolled. Relapse-free survival of the subgroups classified according to width of subserosal invasion was compared to that of 34 patients with T4aN0 cancer. Results: The group with wide invasion (≥1.5 cm) had a significantly poorer prognosis than those with narrow invasion (

Background: Patients undergoing major surgery often experience “post-operative dysfunction”, which may affect their physical strength and mental activity for a significant period post-operatively. We aimed to clarify the post-operative changes in physical activity, quality of life, and self-efficacy in patients with gastric cancer. Methods: Physical activity, health-related quality of life, and self-efficacy were assessed in subjects using self-administered questionnaires before surgery, at discharge, and 1, 3, and 6 months after discharge. Post-operative parameters were compared to baseline data using the Friedman test with Bonferroni correction, as well as the Wilcoxon two-sample test. Results: Seventeen subjects were included. Dietary intake and number of steps walked significantly decreased for up to 1 month after discharge, whereas physical activity of ≥3 metabolic equivalents of task and exercise-expended energy were lowest at discharge. These differences were all statistically significant. Importantly, the patients did subsequently improve. Body mass index did not differ significantly at discharge, but showed a gradual, significant decrease at 1 and 3 months after discharge. With respect to health-related quality of life, the physical, role, and social functions decreased significantly for a month after surgery, whereas symptoms of fatigue, anorexia, and diarrhea were significantly severe during the first month after discharge. Self-efficacy in terms of symptoms, activities of daily living, and disease status significantly decreased at discharge, but subsequently improved. Conclusions: Patients with gastric cancer showed lower dietary intake and body mass index up to 1 and 3 months after discharge, respectively. Physical activity and self-efficacy were lowest at discharge but improved subsequently. It is necessary, both preoperatively and in the first month following discharge, to provide patients with support that encourages self-management of physical changes and symptoms, and a return to normal levels of physical activity.

The aim of this study was to establish the efficacy and safety of doxifluridine and docetaxel for patients with advanced or recurrent gastric cancer.The regimen consisted of oral administration of doxifluridine 533 mg/m(2) per day on days 1-14 and an intravenous infusion of docetaxel 50 mg/m(2) on day 8. The primary endpoint was the overall response rate. The secondary endpoints were overall survival, progression-free survival, and toxicities.Between June 2004 and December 2006, a total of 40 eligible patients were enrolled in this study. Seven of them showed a partial response, with an overall response rate of 17.5%. The response rate was 18.8% in 32 patients with refractory tumors. The median progression-free survival time and the median overall survival time were 2.6 months and 12.7 months, respectively, in all 40 patients; and 2.6 months and 14.0 months, respectively, in the 32 patients with refractory tumors. Grade 3/4 hematological toxicity included neutropenia in 52.5%, leukocytopenia in 17.5%, and febrile neutropenia in 7.5%. Grade 3 or more nonhematological toxicities were infrequent.The combination chemotherapy of doxifluridine and docetaxel was well tolerated and relatively effective when used as a second-line chemotherapy for advanced or recurrent gastric cancer.

症例は53歳, 男性. 既往に48歳時, 胃潰瘍出血にて幽門側胃切除術 (B-I) 施行歴あり. 心窩部痛を主訴に近医受診. 精査にて腹腔内出血と診断され当院へ搬送された. 腹部CTにて上腹部に貯留液と膵尾部から小網の腹側にsentinel clot signを認め急性期の出血が疑われた. 緊急血管造影検査にて左胃大網動脈に3mm大の瘤状の拡張像を認めた. 明らかな出血像は認めなかった. 以上より左胃大網動脈瘤破裂と診断した. 全身状態が比較的安定し出血がコントロールされている為, 保存的に経過観察し待機手術の適応とした. 手術は左胃大網動脈瘤切除術を施行した. 左胃大網動脈からの大網枝に径20mm大の動脈瘤を認め切除した. 切除標本の病理所見では仮性動脈瘤と診断された. 経過良好で, 術後7日目に退院となった. 内臓動脈瘤の破裂の中で全身状態が安定している場合は待機手術可能例もあるが, 迅速な診断と治療適応の判断が必要であると考えられた.

Aims The purpose of this study was to confirm whether the endoscopical mucosal resection for early gastric replace to the traditional gastrectomy on the view point of long term patients' outcomes.Methods Among consecutive series of 1298 patients with early gastric cancer (EGC), a total of 214 cases with EGC endoscopically resected from May 1989 and December 2001 were included in the study. Among them 26 patients (11.6%) underwent additional EMR followed by surgery, because of the residual cancer, and they received 17 distal gastrectomy (DG), 7 proximal gastrectomy (PG), and 2 total gastrectomy (TG). The rest 188 patients were received EMR only and were followed without gastrectomy. Eight hundred fifteen patients received DG, 135 PG, 107 TG, 11 wedge-resection of the stomach and 5 resection of the rest stomach between July 1975 and December 2001. Between July 1975 and April 1989, 369 patients received distal gastrectomy (DG), 30 proximal gastrectomy (PG), 52 total gastrectomy (TG), 2 wedge-resection of the stomach and 2 resection of the rest stomach.Results Ten-year survival rates of patients underwent distal G, PG, TG, wedge-resection, resection of the rest stomach, and EMR were, 81.1%, 70.4%, 52.0%, 42.1%, 0%, and 49.2%, respectively. There were significant differences between DG and EMR (log rank test, p

Atypical carcinoid (endocrine cell carcinoma) of the breast which is a rare entity is reported. A 76-year-old woman had a palpable tumor 3.2×2.7cm in size in the ABC area of the left breast. Echography revealed a broad-based intracystic tumor. Dynamic MRI mammography revealed early enhanced intracystic tumor. A aspiration cytology resulted in class IV. Intraoperative frozen section diagnosis was intracyctic solid-tublar carcinoma, and a modiffied radical mastectomy (Auchincloss's method) was performed. Hematoxylin and eosin (HE) stain showed carcinoid like appearance. Grimerius silver staining demonstrate numerous argyrophillic granules in the cytoplasm of many tumor cells. And chromogranin A stain was positive. Mucin stain also revealed mucin in the cytoplasm. Electron microscopy of the tumor showed numerous neurosecretory granules. At last, from the figure of tumor cells, diagmosis was atypical carcinoid (endocrine cell carcinoma) of the breast. Lymph node metastasis was not seen. Estrogen receptor (ER) was positive, but progesterone receptor (PgR) was negative. No distant metastasis was found at the time of operation. She died of multiple liver metastasis 10 months after the operation. Carcinoid syndrome was not found.

BACKGROUND The aim of this study was to determine by radioisotope use whether the sentinel lymph node concept is applicable to esophagogastric cancers. In addition, we examined radioactivities of hot nodes and compared them with the sensitivity of a gamma probe. METHODS The subjects were 44 patients, 23 with esophageal cancer and 21 with gastric cancer. The day before surgery, patients underwent endoscopic submucosal injection of 184 MBq of Tc-99m tin colloids into sites surrounding the tumor. Radioisotope activities of lymph nodes dissected at surgery were measured with a well-typed gamma detector and each lymph node was categorized as a hot or cold node. Histopathology of the lymph nodes was examined by hematoxylin and eosin staining. Radioisotope activities and histopathological results were compared to determine whether radioisotope flow reflects lymphatic flow to regional lymph nodes. The sensitivity of a gamma probe was measured in a laboratory study and the relation between the radioisotope activities of hot nodes and the detection sensitivity of the gamma probe was examined. RESULTS Histopathological examination revealed lymph node metastasis in 18 of the 44 patients. In 15 of these 18 patients, metastatic foci were recognized in at least one hot node. Subsequent analysis was performed on the 36 patients in whom tumor invasion was confined to the muscle layer and in whom endoscopic clippings had not been applied. Lymph node metastases were observed in 12 of these 36 patients. In these 12 patients, at least one hot node was positive for metastasis. The laboratory study revealed that the gamma probe was able to detect radioisotope activities of >/=0.02 micro Ci. Thirty-two of 63 (51%) esophageal cancer hot nodes and 16 of 86 (19%) gastric cancer hot nodes showed radioisotope activities below the detection sensitivity of the gamma probe. CONCLUSION The sentinel lymph node concept is applicable to patients with esophageal and gastric cancers; however, further studies are necessary to identify hot nodes accurately using gamma probes.

Background For early gastric cancer located in the upper third of the stomach, we have adopted laparoscopic 1/2-proximal gastrectomy (PG) with two types of reconstruction: double tract reconstruction (L-DT) and jejunal interposition reconstruction with crimping of the jejunum on the anal side of the jejunogastrostomy with a knifeless linear stapler (L-JIP). Methods Functional outcomes were prospectively compared between these two types of reconstruction following laparoscopic PG. Resection and reconstruction were performed using L-DT (n = 10) and L-JIP (n = 10) alternately. Quality of life was evaluated through a questionnaire and endoscopic examination of the ten patients in each group, and functional evaluations were carried out in five patients of each group. Results The postoperative/preoperative body weight ratio was significantly higher in the L-JIP group than in the L-DT group. While the incidence of reflux esophagitis was 10% in both groups, the endoscope could reach the remnant stomach in all patients. In the L-DT group, the plasma acetaminophen concentration at 15 minutes and the insulin level at 30 minutes were markedly increased after oral administration, while the increases in the blood sugar level at 30 and 60 minutes were more gradual than in the L-JIP group. Conclusions While L-JIP may be thought of as the ideal method for function-preserving gastrectomy, L-DT may be suitable for gastric cancer patients with impaired glucose tolerance. These results raise the possibility of individualized selection of reconstruction for gastric cancer patients with various kinds of preoperative complications.