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The techniques of intracorporeal anastomosis and specimen extraction after laparoscopic colectomy via a natural orifice have gained interest increasingly. We evaluated the feasibility of our unique techniques for colorectal reconstruction and report immediate postoperative outcomes in patients with rectosigmoid cancer.Patients with sigmoid or rectal cancer were selected depending on the size of the tumor and its distance from the anal verge. Demographic data, operative parameters, and postoperative outcomes were assessed. After complete resection of the tumor, all patients underwent an intracorporeal side-to-end colorectal anastomosis following transrectal specimen extraction.Laparoscopic resection with our technique of intracorporeal anastomosis was successful in 32 patients. The average operative time was 192 ± 29 min, and mean blood loss was 51 ± 18 ml. All patients experienced mild postoperative pain, and bowel function returned before postoperative day 3 in most patients. They had an uneventful postoperative course with a median hospital stay of 6 days. Major perioperative complications or anastomotic leak were not encountered in this study. The mean size of the lesion was 3.3 ± 1.8 cm, and the mean number of harvested nodes was 14 ± 6. During the follow-up period, there were no functional disorders associated with the intracorporeal anastomosis or transrectal specimen extraction.Intracorporeal side-to-end colorectal anastomosis with transrectal specimen extraction in laparoscopic colorectal surgery is a safe and effective procedure for patients with rectosigmoid malignancy.

Purpose We evaluated the safety and efficacy of biweekly capecitabine in combination with oxaliplatin in previously untreated patients with locally advanced or metastatic gastric cancer. Methods Patients received oral capecitabine 1,000 mg/m2 twice daily on days 1–10 plus oxaliplatin 85 mg/m2 as a 2-h intravenous infusion on day 1, every 2 weeks (XELOX). The primary endpoint was overall response rate. Secondary endpoints included progression-free survival, overall survival, and toxicity. Results From March 2007 to October 2010, 46 patients were enrolled in this phase II study. The median age was 64 years (range 32–85). A total of 391 (median 7.5, range 1–29) cycles were delivered. Among the 41 patients evaluable for tumor response, 9 showed partial response and 25 had stable disease. The overall response rates of the evaluable and intent-to-treat (ITT) populations were 22 % (95 % CI 10–42 %) and 20 % (95 % CI 9–34 %), respectively. In the ITT analysis, the progression-free survival and overall survival were 5.6 months (95 % CI 4.1–6.3 months) and 8.0 months (95 % CI 6.3–10.1 months), respectively. The most common hematological toxicities were thrombocytopenia (35 %) and leucopenia (34 %), whereas the most common non-hematological toxicities were neuropathy (35 %), fatigue (33 %), diarrhea (27 %), vomiting (26 %), and hand-foot syndrome (25 %). Major grade 3–4 toxicities were anemia (11 %), diarrhea (9 %), and hand-foot syndrome (7 %). No patient died of treatment-related toxicities. Conclusions Although the biweekly XELOX regimen failed its primary response rate endpoint, it showed modest efficacy and an acceptable safety profile in the treatment of advanced gastric cancer.

Summary Adult intussusception is relatively rare, and in most cases is associated with underlying pathology that draws attention to the condition. The most common initial presentation is a variety of obstructions. A 55-year-old man complained of bloody stools for 5 days. Ileoileal intussusception was suspected on abdominal computed tomography imaging. During exploratory laparotomy, an intussusception caused by a tumor was identified 50 cm proximal to the ileocecal valve, and segmental resection of the ileum with an end-to-end anastomosis was performed. The excised bowel segment had a polypoid submucosal mass, measuring 5.1 cm in size. Immunohistopathological examination revealed an inflammatory fibroid polyp. This case report shows that intussusceptions secondary to an inflammatory fibroid polyp, although rare in adults, should be considered in the differential diagnosis of bloody stools.

Background The identification of KRAS, BRAF, and PIK3CA mutations before the administration of anti-epidermal growth factor receptor therapy of colorectal cancer has become important. The aim of the present study was to investigate the occurrence of KRAS, BRAF, and PIK3CA mutations in the Taiwanese population with colorectal cancer. This study was undertaken to identify BRAF and PIK3CA mutations in patients with colorectal cancer by high-resolution melting (HRM) analysis. HRM analysis is a new gene scan tool that quickly performs the PCR and identifies sequence alterations without requiring post-PCR treatment. Methods In the present study, DNAs were extracted from 182 cases of formalin-fixed, paraffin-embedded (FFPE) colorectal cancer samples for clinical KRAS mutational analysis by direct sequencing. All the samples were also tested for mutations within BRAF V600E and PIK3CA (exons 9 and 20) by HRM analysis. Results The results were confirmed by direct sequencing. The frequency of BRAF and PIK3CA mutations is 1.1%, and 7.1%, respectively. Intriguingly, we found that nine patients (4.9%) with the KRAS mutation were coexistent with the PIK3CA mutation. Four patients (2.2%) without the KRAS mutation were existent with the PIK3CA mutation. Two patients (1.1%) without the KRAS mutation were existent with the BRAF mutation. Conclusions In the current study, we suppose that HRM analysis is rapid, feasible, and powerful diagnostic tool for the detection of BRAF and PIK3CA mutations in a clinical setting. Additionally, our results indicated the prevalence of KRAS, BRAF, and PIK3CA mutational status in the Taiwanese population.

PURPOSE We aimed to evaluate the feasibility of staged laparoscopic colectomy for acute malignant colon obstruction. METHODS Through a laparoscopic approach, emergency blowhole colostomy and subsequent elective resection were performed. RESULTS There were 14 men and 8 women, ages ranging from 42 to 79 years. All patients underwent laparoscopic blowhole colostomy for fecal diversion. Of these stomas, 6 were located at the splenic flexure, 7 at the descending colon, and 9 at the sigmoid colon. Subsequently, 20 of the 22 patients achieved an elective laparoscopic resection including takedown of the stoma. They were left hemicolectomy in 11 and anterior resection in 9. The mean total length of hospital stay was 20 ± 4.6 days (range, 16 to 33 d) in these 20 patients. The remaining 2 patients did not undergo reversal of the colostomy. The median follow-up period was 23 months. Seven patients died of disease progression and 15 patients remained alive and well. CONCLUSIONS Our results suggest that staged laparoscopic colon resection is a feasible and effective technique for acute malignant colonic obstruction. The length of hospital stay is justified as compared with conventional single-staged resection. Our technique can also be recommended when colonic stenting is not available.

The objective of this study is to explore the inflammatory modulation effect of glutamine-enriched total parenteral nutrition (TPN) by investigating the alterations of inflammation-related cytokines in gastrointestinal (GI) cancer patients postoperatively. Fifty GI cancer patients received postoperative 7 days of isocaloric and isonitrogenous TPN after operation. They were randomly divided to receive either glutamine-enriched TPN or standard TPN. The inflammation-related cytokines including interleukin-6, interleukin-10, and tumor necrosis factor-α were also determined. Records of nutritional assessments, inflammatory status, and postoperative complications were compared between the two groups. Of 50 enrolled patients, 25 patients were classified as the intervention group, and the control group also comprised 25 patients. The differences of gender, age, primary GI malignancies, and hematological and biochemical data between the two compared groups were not statistically significant (all P > 0.05). Compared with standard TPN, a higher serum prealbumin level and better nitrogen balance were observed in glutamine-enriched TPN ( P = 0.039 and 0.048 respectively). A significantly lower serum interleukin-6 level was found in comparing glutamine-enriched with standard TPN ( P = 0.01), but not in interleukin-10 ( P = 0.374) and tumor necrosis factor-α levels ( P = 0.653). Moreover, a significant lower serum C-reactive protein level was detected in glutamine-enriched TPN compared with standard TPN ( P = 0.013). Indeed, four cases of postoperative infectious complications were noted in the control group, but no postoperative infectious complications were observed in the interventional group ( P = 0.037). Our present study shows that glutamine-enriched TPN may be beneficial in improving the inflammatory status and decreasing the infectious morbidity in postoperative GI cancer patients.

This report describes a patient with a gastrointestinal stromal tumor (GIST) and upper gastrointestinal hemorrhage as initial presentations of the Carney triad, a synchronous or metachronous condition involving gastric leiomyosarcoma, extra-adrenal paraganglioma and pulmonary chondroma. A 26-year-old woman presented with dizziness and several episodes of melena over 3 days. Physical examination revealed pale conjunctiva but normal hemodynamic status. Gastroendoscopy showed one antral submucosal tumor with evidence of an associated bleeder (the bleeder over the mucosal surface of the gastric tumor). An abdominal computed tomography scan showed an antral submucosal tumor, two secondary lesions over segment II/V of the liver and a retroperitoneal tumor. Surgical removal of the tumor and subsequent recovery were uneventful. The gastric GIST with liver metastasis and retroperitoneal paraganglioma were confirmed by pathologic study. The patient was treated with imatinib mesylate for the GIST with liver metastasis, and continued follow-up treatment at our hospital. An abdominal computed tomography scan at 32 months after surgery showed no change in the liver metastatic lesions and no evidence of local recurrence. Another follow-up visit at 33 months after surgery confirmed the stable condition. Of nearly 100 cases reported in the literature, this case is the first to be reported in Taiwan. This case highlights the possibility of this rare syndrome occurring in young female patients with one of the three components of the triad and the need for further diagnostic studies for early identification of tumors when curative surgery is still possible.

Postoperative enteric fistula is a serious complication and cause of death following gastrointestinal (GI)-tract surgery. Many reports have demonstrated the effectiveness of parenteral nutrition in the spontaneous closure of enteric fistula. Our study was aimed at analyzing the prognostic factors of parenteral nutritional support in the treatment of enteric fistula for patients with GI-tract cancer following surgery. GI-tract cancer patients receiving surgical interventions, which then unfortunately developed enteric fistula, were included in our study. All of them had to have received parenteral nutrition soon after leakages were recognized, and they were subsequently divided into successful and unsuccessful (classified as "failure") groups according to spontaneous closure of fistula or not, respectively. The studied patients' laboratory data were collected to identify the clinically relevant prognostic factors. Fifty-three primary GI-tract cancer patients with postoperative enteric fistulas were enrolled into our study. Of these, 33 patients were considered as successful parenteral nutritional therapy (successful group) and the other 20 patients (failure group) were not. After a period of parenteral nutritional therapy, serum total bilirubin, creatinine, C-reactive protein (CRP), hemoglobin, and albumin were significantly different between these two groups (all p.05). Using a multivariate logistic regression analysis, it was determined that increased serum albumin level was an independent predictive factor of successful management for enteric fistula (p = .029), in addition to the well-known lower drainage amount (500 mL/day) from the enteric fistula (p = .013). Our observations show that both serum albumin levels and drainage amounts from the enteric fistula can be potentially used as important prognostic predictors of healing enteric fistula under total parenteral nutrition in patients following surgery for GI-tract malignancies.

In patients with radically resected colorectal carcinoma, lymph node involvement is particularly important for a good prognosis and adjuvant therapy. The number of such lymph node recoveries is still controversial, with recommendations ranging from 6 to 17 nodes. The aim of this study is to determine if a specified minimum number of lymph nodes examined per surgical specimen can have any effect on the prognosis of patients who have undergone curative resection for T(2-4)N(0)M(0) colorectal carcinoma. Between September 1999 and January 2005, a total of 366 patients who underwent radical resection for T(2-4)N(0)M(0) colorectal carcinoma were retrospectively analyzed in a single institution. All specimen segments were fixed, with node identification performed by sight and palpation. We excluded 186 patients who received postoperative adjuvant chemotherapy via oral or intravenous transmission to prevent possible chemotherapeutic effects on patients' prognosis; therefore, a total of 180 patients with T(2-4)N(0)M(0) colorectal carcinoma were enrolled into this study. After the pathological examination, a mean of 12 lymph nodes (range 0-66) was harvested per tumor specimen. No postoperative relapse was found in this group, where the number of examined lymph nodes was 18 or more. Univariate analysis identified the size of the tumor, depth of invasion, grade of tumor, and number of examined lymph nodes, which were significantly correlated with postoperative relapse (all P0.05). Meanwhile, both the depth of tumor invasion and the number of harvested lymph nodes were independent predictors for postoperative relapse (P0.05). The 5-year overall survival rate of T(2-4)N(0)M(0) colorectal carcinoma patients who had 18 or more lymph nodes examined was significantly higher than those who had less than 18 nodes examined (P = 0.015). Nodal harvest in patients undergoing radical resection for colorectal carcinoma was highly significant in the current investigation. Our results suggest that harvesting and examining a minimum of 18 lymph nodes per surgical specimen might be taken into consideration for more reliable staging of lymph node-negative colorectal carcinoma.

To prospectively evaluate accuracy of multi-detector row computed tomographic (CT) images for preoperative staging of gastric cancer by using surgical and histopathologic results as reference standards.This study had institutional review board approval; informed consent was obtained from all patients. Multi-detector row CT included acquisition of virtual gastroscopy images after air distention and contrast material-enhanced dynamic transverse and multiplanar reformation (MPR) images after water distention. Fifty-five consecutive patients with gastric cancer (38 men, 17 women; age range, 37-84 years; mean age, 63 years) underwent preoperative CT. All received 6 g of gas-producing crystals before unenhanced CT scanning for gastric distention and virtual gastroscopy. Patients drank 800-1000 mL of tap water to establish a background for dynamic contrast-enhanced CT scans. Images were obtained in late arterial, portal venous, and delayed phases with start delays of 40, 70, and 150 seconds, respectively. All patients underwent surgery. CT findings were compared with surgical and histopathologic results. Differences in accuracy of transverse and MPR images for T and N staging were assessed with the McNemar exact test. Statistical significance was inferred at P.05.Detection rates of primary tumors with transverse images, MPRs, and combinations of MPR and virtual gastroscopy images were 91% (50 of 55), 96% (53 of 55), and 98% (54 of 55), respectively. Overall accuracy in assessment of tumor invasion of the gastric wall (T stage) was significantly better with MPR images (89% [49 of 55]) than with transverse images (73% [40 of 55]) (P.01). Overall accuracy for lymph node (N) staging was 78% (43 of 55) with MPR images and 71% (39 of 55) with transverse images. This difference was not significant (P = .103).Multi-detector row CT with combined water and air distention can improve the accuracy of preoperative staging of gastric cancer. MPRs yield significantly better overall accuracy than transverse images for tumor staging but not for lymph node staging.

Laparoscopic gastrostomy is the best alternative for long-term enteral feeding when percutaneous endoscopic gastrostomy is not possible. The aim of the present study was to determine the feasibility, complications, adequacy of feeding support, and tolerability of laparoscopic Witzel gastrostomy (LWG) in head and neck cancer patients. The initial results and the results of extended follow-up were evaluated.A consecutive series of 48 patients with stenotic head and neck or esophageal cancer were referred for laparoscopic gastrostomy. The patients consisted of 42 men and 6 women aged 36 to 82 years (mean, 54 years). After laparoscopic placement of a Foley catheter of 16 F into the stomach, a seromuscular tunnel 4 cm in length is created, embedding the catheter by interrupted sutures. Three stay sutures for gastropexy are fixed and tied on the abdominal skin at the end of the procedure. The mean duration of the procedure was 62.4 +/- 11 min (52-124 min).Laparoscopic Witzel gastrostomy could be performed successfully in all patients with aerodigestive cancer. None of the laparoscopic gastrostomy tube placement procedures was converted to an open surgery, and none of the 48 patients in this series died as a result of the laparoscopic procedure. All LWG complications (11%) were minor, consisting of superficial wound infections, balloon rupture, and chronic granulation. No major complications were encountered. The mean usage time of gastrostomy was 6.3 +/- 5.3 months.Current techniques of LWG could be an alternative to percutaneous endoscopic gastrostomy (PEG) for long-term enteral access, because it has proved to be safe and reproducible with relatively few complications.

Most cancer patients often neglect the possibility of secondary cancer. Colorectal cancer (CRC) is the third leading cause of cancer death in Taiwan. It is important to be aware of the clinical characteristics of double cancer in CRC patients for early diagnosis and treatment. We retrospectively analyzed 1,031 CRC patients who underwent surgical treatment at the Department of Surgery of Kaohsiung Medical University Hospital between January 1998 and December 2004. Among these patients, CRC was accompanied by cancer of other organs in 17 patients (1.65%), either synchronously or metachronously. Therefore, we describe our experience regarding the location of CRC, the clinical symptoms and signs of these patients, the TNM stage, histology, phase, association with other malignancies, interval between cancers and clinical outcomes. Of the 17 patients in whom CRC was accompanied by primary cancer of other organs, there were four synchronous and 13 metachronous multiple cancer patients. Our patient group comprised six men and 11 women with ages ranging from 47 to 88 years (median age, 66 years). The most common location of CRC was the sigmoid colon. Six gastric cancers (35.2%) and six breast cancers (35.2%) were associated with primary CRC. The remaining six second primary cancers were one lung cancer, one thyroid cancer, one cervical cancer, one ovarian cancer, one skin cancer, and one urinary bladder cancer. Of the 13 metachronous multiple cancer patients, eight patients developed subsequent CRC after primary cancers of other organs, whereas two patients developed a subsequent second primary cancer after CRC. The intervals between the development of metachronous multiple cancers ranged from 2 to 19 years. In this retrospective analysis, breast and gastric cancer patients were at increased risk of developing subsequent secondary CRC. Careful attention should always be paid to the possibility of secondary CRC in treating these cancer patients. Cancer patients with hematochezia or gastrointestinal symptoms/signs should be evaluated for the possibility of second primary CRC during their regular follow-up.

To prospectively identify histologically and endoscopically the effect of omeprazole on the expression of endothelin-1 (ET-1), inducible nitric oxide synthase (iNOS) and macrophage inflammatory protein-1alpha (MIP-1alpha) in the gastric mucosa of neurosurgical patients with stress ulcer.Twenty-five patients with severe acute intracranial lesions caused by trauma were enrolled in this study. A 40 mg intravenous bolus of omeprazole (OME) was given daily for 7 days. The intragastric pH was continuously recorded for 24 hours on day 1 and 8. Endoscopic evaluation of the gastric corpus, antrum, and duodenal bulb was performed in the ICU, within 24 hours after brain injury, and at follow-up on the 7th day after admission. Paired biopsies were obtained for histologic examinations and immunohistochemical analysis was performed using a LSAB method for MIP-1alpha, ET-1, and iNOS.There were 72% and 70% of gastroduodenal mucosal lesions at the initial and follow-up endoscopies, respectively. However, the severity of mucosal lesions showed significant improvement in most patients at follow-up (p0.05). Mean percentages of time intragastric pH were greater than or equal to 4.0 were 20 +/- 11% and 70 +/- 17% on day 1 and 8, respectively (p0.05). The incidences of ET-1, iNOS and MIP-1alpha expression were not significantly different between the patients before and after OME prophylaxis.Prophylactic OME is effective in reducing the severity of stress ulcerations in severe neurotraumatic patients. High incidence of tissue ET-1 expression combined with increased activity of iNOS and MIP-1alpha may be responsible for the gastric mucosal injury. We also show that OME fails to counter the enhancement in the mucosal expression of ET-1, iNOS, and MIP-1alpha caused by severe brain damage.

Capsule endoscopy (CE) is used to diagnose small intestine disease. Many studies have shown a better lesion detection rate in obscure gastrointestinal (GI) bleeding than with other surveyed techniques. Our study investigates the diagnostic value of CE in patients with suspicious small intestine diseases. Between October 2004 and January 2006, patients who had suspected small intestine disease underwent CE in Kaohsiung Medical University Hospital. Presenting symptoms included obscure GI bleeding, abdominal pain, diarrhea, microcytic anemia, and other indications. CE results were analyzed as a proportion of total lesion detection rate and also with regard to obscure GI bleeding and abdominal pain for analysis. A total of 28 patients, including 12 males and 16 females, were enrolled for CE examination. Overall, small intestine lesions were detected in 20 cases (71.4%), with negative findings in eight cases. For obscure GI bleeding, the total lesion detection rate was 85.7% (12 of 14 patients) but the diagnostic rate was only 35.7% (five of 14 cases). In patients with abdominal pain, four of seven (57.1%) had small intestine lesions. In conclusion, CE survey has a good lesion detection rate for small intestine disease, especially for patients with obscure GI bleeding, and is helpful in the diagnosis of unexplained abdominal pain.

Mesenteric ischemia is a devastating disease process that frequently challenges clinicians. To enhance the early diagnosis of gut ischemia and judgment of its severity, it may be helpful to detect the unusual existence or increase in biomarkers in the body fluid. The aim of the present study was to evaluate the correlation of plasma nitric oxide (NO) and endothelin-1 (ET-1) levels to mesenteric ischemia using an animal model. Acute mesenteric ischemia (AMI) was produced experimentally by occlusion of the mesenteric vessels in the terminal ileum by the tenting of a thread. The determination of plasma NO and ET-1 levels were obtained before operation (T0, baseline value), and at 10 (T10), 20 (T20), 30 (T30), and 60 (T60) min after the creation of AMI. Sham-operated rats served as controls. After 30 min of experiments, the plasma NO and ET-1 levels were significantly higher in the AMI group than in the control group (both p.01). Both the plasma NO and ET-1 levels in AMI group increased significantly after 30 min of ischemia (both p.001 vs. respective baseline value), and they were 60% and 84% above the baseline value, respectively. In addition, ischemic intestinal injury was confirmed by the significantly elevated histological scores in the AMI group after 60 min of ischemia (p.001). Our preliminary results suggest the possibility of important insights regarding NO and ET-1 changes into the mechanism of pathogenesis in AMI in rats. The increases in plasma NO and ET-1 levels may potentially be noninvasive biomarkers for the early detection of this disease.

In this article, we will discuss the achievement of early dynamic lymphoscintigraphic protocol and compare detection of sentinel node between benign and malignant breast tumors, and whether pathologic factor is related or not.During a six-month period, consecutive fifty-nine patients were enrolled into our study. The average age of patients was 47.6 +/- 9.8 years and all of them were clinically suspected of having breast cancer. The average tumor was 2.1 +/- 1.1 cm in size. First, Tc-99m sulfur colloid was injected around corners of palpable mass or biopsy cavity by the hybrid injection method. Immediately thereafter, dynamic protocol of lymphoscintigraphy, with 10 sec per frame for 60 frames was performed by established simultaneous dual-head vertical angle imaging technique. And delayed two-hour image was also acquired. All patients underwent surgery sixteen to twenty hours later and had a final pathological diagnosis.Among 59 patients, 14 of them were diagnosed with fibroadenoma and the other 45 cases with malignant conditions, infiltrating duct carcinoma mostly. The average age of the two groups was similar. From the summation image of dynamic study, identified axillary sentinel nodal activity was found as 80% in the group of benign breast tumor, but only 48% in the group of malignant breast tumor. In more than 88% of patients, sentinel lymph node was detectable on the delayed two-hour image between the two groups.Early dynamic protocol of pre-operative lymphoscintigraphy is helpful to clarify the relationship between the local lymphatic drainage basin and sentinel nodal uptake. However, this short period of protocol is not always achievable to detect sentinel node, especially in the group with breast malignant lesions.

Somatic mutation of BRCA2 has been thought to be rare in breast cancers, though common allelic deletions in the BRCA2 locus (13q12-q13) imply an important role of somatic mutation in these tumors. Reasons of the reported rare incidence could be related to very few studies focusing on the mutational analysis of BRCA2 in sporadic tumors. The mutational status of the BRCA2 gene in exon11, the largest exon harboring the RAD51 interacting BRC domains which are critical for BRCA2 function, was screened by polymerase chain reaction/single strand conformation polymorphism (PCR-SSCP) analysis followed by direct sequencing. Tumor and paired normal tissue sample from 175 patients unselected for family history or age were taken after mastectomy for breast cancer and evaluated. There were 20 mutations of BRCA2 gene in exon 11 in 15 cases (15/175, 8.6%). Most mutations we identified were point mutation (19/20, 95%), except for one nucleotide insertion. Furthermore, among these mutations, missense mutations comprised 80% (16/20) of the BRCA2 mutations. All mutations we found were novel mutation after searched in the BIC database. There were three recurrent mutations at codon 1904; and two recurrent mutations at 1907, 1936, 1937 and 1968, respectively. The mutations were associated with ductal carcinoma in situ (P=0.038) and borderline with low histological grade (P=0.072). Besides, there were three cases possessing multiple mutations in the region we studied and one of them demonstrated aggressive lymph node metastasis. These findings implicated that somatic mutations of BRCA2 genes may play a significant role in the pathogenesis of breast carcinoma in Taiwan. In addition, those events were associated with some early clinicopathological features.

Peritoneal dialysis is an established alternative method for the management of patients with end-stage renal disease. Recently, laparoscopy has been utilized in assisting the insertion of catheters under direct vision. The efficacy of the laparoscopic approach for patients with a history of abdominal surgery remains largely unknown. The purpose of this study is to evaluate laparoscopy in the placement of peritoneal dialysis catheters for selected patients with previous abdominal operation. Laparoscopic assisted placement of peritoneal dialysis catheters was performed in 20 patients, who were carefully selected preoperatively and who also underwent previous abdominal operation between April 1999 and July 2001. Previous abdominal operation included appendectomy, ovarian resection, hysterectomy, cesarean section, open cholecystectomy, segmental resection of the small intestine, and truncal vagotomy with pyloroplasty. The procedure was performed using two 10-mm and one 5-mm abdominal trocar. All of the patients tolerated this procedure without significant surgical complications. However, 3 patients developed temporary hemoperitoneum, and 1 patient developed dialysate leakage. The overall success rate of catheter function (> 30 days after laparoscopy) was 90%, except in 2 cases where the catheter functioned poorly due to severe intra-abdominal adhesions. Simultaneous laparoscopic adhesiolysis was successfully performed in 5 cases. Laparoscopic implantation of peritoneal dialysis catheters appears to be a straightforward procedure, even for patients with previous abdominal operation. We believe that this technique may extend the application of peritoneal dialysis treatment in patients with previous abdominal surgery after discreet evaluation preoperatively.

Background Gastric cancer is one of the most significant causes of cancer-related death worldwide. A genetic model consisting of sequential accumulations of alterations in specific genes for gastric cancer has been proposed. Materials and methods The significance of adenomatous polyposis coli (APC) and p53 gene mutations in cancer tissues and their paired serum of 34 gastric cancer patients was investigated using polymerase chain reaction single-strand conformation polymorphism analysis (PCR-SSCP), followed by direct sequencing. c- met mRNA expression was evaluated by reverse-transcription PCR (RT-PCR). Additionally, analyses were carried out to detect the serum carcinoembryonic antigen (CEA) levels, and their correlation to these three molecular markers. Finally, serum molecular markers and their correlation to the presence of postoperative recurrence/metastasis were analyzed. Results Of all, 32.4% of patients presented mutations in APC and p53, respectively, and 58.8% presented the overexpression in c- met , overall, at least one of these genetic alterations in 79.4% of tumor tissues. Comparison of three molecular markers showed that the individual detection rate in the serum of patients with tumors harboring the same abnormalities was 18.2, 70.0, and 36.4% for APC, c- met , and p53 genes, respectively. In general, 59.3% of serum from cancerous tissues with gene alterations was demonstrated as positive, whereas all healthy volunteers’ sera remained negative. Regarding gene alterations in tumor tissues, c- met overexpression was significantly related to the tumor size ( P = 0.017), depth of tumor invasion ( P = 0.007), lymph-node metastasis ( P P = 0.001). In the serum, c- met overexpression was closely associated with lymph-node metastasis ( P = 0.008) and TNM stage ( P = 0.016). The overall positive tumor gene detection rate in the serum was prominently correlated to the serum CEA levels ( P = 0.038). In addition, a significantly higher postoperative metastasis/recurrence rate in patients harboring gene mutations with serum molecular markers than those without serum molecular markers was also demonstrated ( P = 0.014). Conclusions Our findings suggest that serum molecular markers can be detected in a substantial proportion of gastric cancer patients, and these may offer an auxiliary approach in the noninvasive detection and prognosis of gastric cancer.

Abdominal actinomycosis is an infrequent chronic, suppurative infection caused by the aerobic gram-positive bands Actinomyces israelii. We report two cases of abdominal actinomycosis, simulating colon cancer. Before operation, both patients presented with abdominal pain and a palpable mass. Abdominal computed tomography (CT) revealed an infiltrating irregular mass in the cecum and transverse colon, respectively. Surgical intervention was then performed under the impression of colonic malignancy. Postoperatively, pathologic examination confirmed the diagnosis of abdominal actinomycosis in which the characteristic finding of sulfur granules in the resected specimen was demonstrated. After surgery, the patients continued antibiotic treatment with ampicillin for 2 months at our OPD and had no signs of recurrence 1 year after surgery.

Background and Objectives The aim of this study is to clarify the relationship between the expression of MUC1 and MUC5AC mucins and the clinicopathological features in human gastric carcinomas using the mouse monoclonal antibodies VU-4H5 and Clone 45M1, respectively. Furthermore, the possibility of using phenotypes (MUC1+/MUC5AC+, MUC1+/MUC5AC−, MUC1−/MUC5AC−, MUC1−/MUC5AC+) to predict prognosis of the patients is evaluated. Methods Formalin-fixed, paraffin wax-embedded tissues from 76 cases of gastric cancer were examined for the expression of MUC1 and MUC5AC mucin antigens immunohistochemically using the avidin–biotin-peroxidase method. Results Of the 76 cases, MUC1 and MUC5AC immunoreactivities were observed in 49 (64.5%) and in 32 (42.1%) of gastric carcinoma tissues, respectively. MUC1 expression was significantly correlated to the depth of invasion, lymph node metastasis, peritoneal dissemination, and tumor stage. On the other hand, MUC5AC was inversely associated with depth of invasion, lymph node metastasis, liver metastasis, and tumor stage. Multivariate analyses indicated that tumor stage and MUC1 mucin expression were independently correlated with overall survival. The patients with MUC1+/MUC5AC− antigen staining in carcinoma tissues showed the lowest survival rate among four phenotypes. In contrast, the patients with MUC1−/MUC5AC+ antigen staining in carcinoma tissues showed the highest survival rate. Conclusions Altogether these data suggest that combined evaluation of MUC1 and MUC5AC mucin staining may be clinically helpful to predict outcome in patients with gastric cancer. J. Surg. Oncol. 2003;83:253–260. © 2003 Wiley-Liss, Inc.

Gastric cancer (GC) has a high rate of morbidity and mortality among various cancers worldwide. The development of noninvasive diagnostic methods or technologies for tracking the occurrence of GC is urgent, and searching reliable biomarkers is considered.This study intended to directly discover differential biomarkers from GC tissues by two-dimension-differential gel electrophoresis (2D-DIGE), and further validate protein expression by western blotting (WB) and immunohistochemistry (IHC).Pairs of GC tissues (gastric cancer tissues and the adjacent normal tissues) obtained from surgery was investigated for 2D-DIEG.Five proteins wereconfirmed by WB and IHC, including glucose-regulated protein 78 (GRP78), glutathione s-transferase pi (GSTpi), apolipoprotein AI (ApoAI), alpha-1 antitrypsin (A1AT) and gastrokine-1 (GKN-1). Among the results, GRP78, GSTpi and A1ATwere significantlyup-regulated and down-regulated respectively in gastric cancer patients. Moreover, GRP78 and ApoAI were correlated with A1AT for protein expressions.This study presumes these proteins could be candidates of reliable biomarkers for gastric cancer.

To assess the effect of portal hypertension on gastric adherent and soluble mucus in rats.Experimental study.Teaching hospital, Taiwan.30 male Wistar rats.Portal hypertension was induced experimentally by partial ligation of the portal vein in 20 male Wistar rats: ten rats were examined after 4 weeks and the remaining 10 after 8. Another group of 10 rats (controls) had sham operations.Portal pressure, the severity of gross gastric mucosal lesions, and measurement of gastric adherent and soluble mucus.The portal pressure and the gross mucosal damage differed significantly between the experimental and the control groups (p0.01). There was significantly less gastric adherent mucus in the two experimental groups than in the control group (p = 0.002 and0.001, respectively), whereas there was no significant differences in the amount of gastric soluble mucus (p = 0.5 and 0.1, respectively). The reduction in the gastric adherent mucus was closely related to the increase in portal pressure (p0.001) and the severity of portal hypertension-induced gastropathy (p0.001).Gastric adherent mucus may have an important role in the pathogenesis of portal hypertensive gastropathy, and its protective capacity is reduced by portal hypertension, as indicated by the decrease in gastric adherent mucus.

We performed a prospective study from November 1989 to December 1996 to assess the accuracy of endoscopic ultrasonography (EUS) in the locoregional staging and resectability of patients with gastric carcinoma. One hundred and nineteen patients with gastric cancer who received preoperative assessment by EUS underwent subsequent surgery. The endosonographic tumor-node-metastasis (TNM) classification was used for comparison with the histopathologic findings of the resected specimens. The ability of EUS to accurately predict the T stage (depth of tumor invasion) and N stage (involvement of lymph node) was 70% and 65%, respectively. EUS dis- played a tendency to overestimate T stage and underestimate N stage. The differentiation of early gastric cancer from advanced gastric cancer showed a concordance rate of 89% with an overestimation rate of 8% and underestimation rate of 3%. The accuracy of EUS in predicting the stage T1 to T3, which correspond to D0 resectability (no macroscopic or microscopic tumor remains), was 91%. In conclusion, these results revealed EUS as a valuable tool for evaluating the local staging and resectability of gastric cancer. We suggest that EUS should be introduced in the preoperative assessment of patients with gastric cancer.

INTRODUCTION Operating on an enlarged spleen via the laparoscopic approach presents several challenges. A homemade bag may facilitate retrieval of the enlarged spleen assisted by a laparoscope and save medical expense. AIM To assess the feasibility and safety of laparoscopic splenectomy for moderate or massive splenomegaly using our technique and a homemade retrieval bag. MATERIAL AND METHODS Fifty patients underwent laparoscopic splenectomy for moderate or massive splenomegaly which was defined as the major axis exceeding 17 cm by abdominal computed tomography. A homemade retrieval bag made from a commercial sterile infusion container which costs about US$ 1-2 per piece was used for spleen retrieval. Two transabdominal sutures for suspension of the retrieval bag were made to aid specimen removal in this technique. RESULTS There were 31 males and 19 females with mean age of 56 ±11 years. Laparoscopic splenectomy was successfully completed in 49 of these 50 patients. Overall, mean operative time was 149 ±31 min (range: 100-252 min). Median estimated blood loss was 189 ±155 ml (range: 50-920 ml). There were 12 minor complications but no mortality. Time to discharge after surgery ranged from 3 to 9 (mean: 4.7 ±1.7 days). The average splenic weight was 729 ±74 g (range: 632-930 g). CONCLUSIONS Our preliminary results indicate that laparoscopic splenectomy is feasible and safe for moderate or massive splenomegaly and may be a well-tolerated alternative to open splenectomy. Not only is the cost of our homemade retrieval bag low, but also it is easy to make and ready to use.

Fifty-seven patients treated by radical gastric resections were retrospectively studied to understand the clinicopathologic characteristics of advanced gastric cancer without serosal invasion (the depth of tumor invasion limited to the muscularis propria or subserosal layer) in young and old age persons. There were 36 patients in the old age group (age > 60 years) and 21 in the young age group (age < or = 40 years). The clinical and pathologic parameters for this study included sex, gross type, location, maximum tumor size, depth of invasion, lymph node metastasis, tumor stage, histologic type, and rate of curative resection. The old patients had a higher percentage of small tumors, subserosal invasion and lymph node metastasis, but these parameters were not significantly different from those of the young patients, nor did the sex ratio, gross type, location, and rate of curative resection show significant differences. The histologic feature was the only statistically significant parameter, determined by univariate and multivariate analyses. Poorly differentiated adenocarcinoma and signet ring cell carcinoma were detected in 10 (47.6%) and 4 (19.0%) of the 21 younger patients, respectively, while there were 4 (11.1%) and 2 (5.6%) in the old age group. Although the gastric cancer in young patients had more aggressive histologic characteristics than it did in elderly patients, survival rates between the two groups did not differ to any great degree. Our findings indicate that the prognosis for younger patients with advanced gastric cancer without serosal invasion was favorable when curative resection was performed.

To investigate, by transhepatic portography, the changes in portosystemic collaterals and recurrent esophagogastric varices after devascularization surgery.Thirty-five patients, who had undergone devascularization surgery 2-8 years previously, underwent follow-up portography and the collaterals and drainage routes were compared with preoperative portography results.Newly formed collaterals were present in 30 of 35 patients and the origins and drainage routes differed from preoperative ones. Most common were new collaterals arising from the junction of the portal and superior mesenteric veins; the next most frequent arose from a main portal branch, the portal trunk, or the superior mesenteric vein. New collaterals with recurrent varices were seen in 20 patients and without varices in 10; 5 patients had no collaterals or varices.Since the development of new collaterals is common in portal hypertensive patients following devascularization surgery, regular follow-up for recurrent varices is necessary.