Endoscopic submucosal dissection and preoperative assessment with endoscopic ultrasonography for the treatment of rectal carcinoid tumors

Background

Rectal carcinoid tumors 10 mm in diameter or smaller located within the submucosal layer can be cured by local excision including endoscopic treatment. But complete resection of these tumors with endoscopic polypectomy is difficult. This study aimed to evaluate the usefulness of endoscopic submucosal dissection (ESD) and endoscopic ultrasonography (EUS) for the treatment of rectal carcinoid tumors.

Methods

In this study, 22 rectal carcinoid tumors in 21 patients were evaluated with EUS and treated using ESD from January 2004 to December 2008.

Results

The mean size of the resected tumors was 6.1 mm (range, 2.0–10 mm) on histopathologic evaluations. When the sizes of the tumors shown by EUS and histopathologic evaluation were compared, the mean values were not significantly different. All the tumors were located within the submucosal layer, and the accuracy of the preoperative depth determination with EUS was 100% (22/22). The mean duration of the ESD procedure was 37 min (range, 20–71 min). The overall rate of en bloc resection with ESD was 100% (22/22). Although postoperative bleeding occurred in two cases (9%), both cases were successfully managed by endoscopic hemostasis. No perforation or recurrence was observed during the mean follow-up period of 30 months (range, 7–66 months).

Conclusions

Endoscopic submucosal dissection and preoperative assessment with EUS are effective for treating rectal carcinoid tumors and enabling en bloc resection.     

New parameters to represent the position of the aorta relative to the spine for pedicle screw placement

Parameters of the position of the aorta in previous reports were determined for anterior surgery. This study evaluated the relative position of the aorta to the spine by new parameters, which could enhance the safety of pedicle screw placement. Three parameters were defined in a new Cartesian coordinate system. We selected an entry point of a left pedicle screw as the origin. The transverse plane was determined to include both the bases of the superior facet and to be parallel to the upper endplate of the vertebral body. A line connecting the entry points of both sides was defined as the X-axis. The angle formed by the Y-axis and a line connecting the origin and the center of the aorta was defined as the left pedicle–aorta angle. The length of a line connecting the origin and the aorta edge was defined as the left pedicle–aorta distance. Distance from the edge of the aorta to the X-axis was defined as the pedicular line–aorta distance. These parameters were measured preoperatively in 293 vertebral bodies of 24 patients with a right thoracic curve. We simulated the placement of the pedicle screw with variable length and with some direction error. We defined a warning pedicle as that when the aorta enters the expected area of the screw. Sensitivity analysis was performed to find the warning pedicle ratio in 12 scenarios. The left pedicle–aorta angle averaged 29.7° at the thoracic spine and −16.3° at the lumbar spine; the left pedicle–aorta distance averaged 23.7 and 55.2 mm; the pedicular line–aorta distance averaged 18.3 and 51.0 mm, respectively. The ratio of warning pedicles was consistently high at T4–5 and T10–12. When a left pedicle screw perforates an anterior/lateral wall of the vertebral body, the aorta may be at risk. These new parameters enable surgeons to intuitively understand the position of the aorta in surgical planning or in placement of a pedicle screw.     

Assessment of pelvic hemodynamics during an open repair of an infrarenal abdominal aortic aneurysm

Purpose  

To assess the pelvic circulation during abdominal aortic aneurysm (AAA) repair by measuring the inferior mesenteric artery stump pressure (IMA-SP), penile blood flow, and gluteal blood flow.     

Prognosis of Japanese Metastatic Renal Cell Carcinoma Patients in the Cytokine Era: A Cooperative Group Report of 1463 Patients

Background

Incidence rate of renal cell carcinoma (RCC) differs among countries. The rates of Asian countries are lower than those of countries in North America or Europe but are exceptionally high in Japanese males. Approximately 30% of patients with RCC have metastasis at initial diagnosis, and another 30% have metastasis after nephrectomy. Clinical studies of risk factors in patients with metastatic RCC (mRCC) are mainly based on data from non-Asian patients.

Objectives

We aimed to investigate the prognosis of Japanese patients and their prognostic factors.

Design, setting, and participants

The subjects of this study were 1463 patients who were clinically diagnosed with RCC with metastasis in 40 Japanese hospitals between January 1988 and November 2002.

Measurements

The primary end point was overall survival calculated from first diagnosis of mRCC to death or last follow-up. We also investigated the relationship between survival and clinical features.

Results and limitations

The median overall survival time was 21.4 mo. The estimated survival rates at 1, 3, 5, and 10 yr were 64.2%, 35.2%, 22.5%, and 9.1%, respectively; they contrasted with data from the United States of 54%, 19%, 10%, and 6%, respectively for the same periods. A high percentage of patients had undergone nephrectomy (80.5%) and metastasectomy (20.8%), both of which were shown to prolong survival.

Conclusions

The median survival time in the present study was approximately twice as long as that of previous studies from North America or Europe. Early diagnosis of metastasis, nephrectomy, metastasectomy, and cytokine-based therapy seemed to improve the prognosis of RCC patients in the present study.     

Factors influencing death at home in terminally ill cancer patients

Aim: The purpose of this study is to investigate factors affecting terminally ill cancer patients dying at home. Material: Ninety‐two terminally ill cancer patients who were receiving home medical care services and died between April 2005 and December 2006 were included in the study. The data included patients' and caregivers' demographic characteristics, disease‐related information, place of death, and status of home care support. To identify the factors predicting the place of death, multivariate logistic regression analyses were performed. Results: Patients of families who had no preference regarding the place of death or a preference for death at home were more likely to die at home (vs preference for hospital death, odds ratio = 5.87, 95% confidence interval = 1.02–36.53; odds ratio = 90.35, 95% confidence interval = 8.15–1001.51, respectively) after adjusting for potential confounders. Meanwhile, if the patient's family preferred that the patient not die at home, the patient's place of death was not at his/her home irrespective of his/her preference. Conclusion: The results suggested the stronger involvement of families' preferences regarding the patients' place of death over patients' own preferences. Therefore, factors affecting families' preferences need to be clarified for the dissemination of death at home for terminally ill cancer patients.     

Absence of invariant natural killer T cells deteriorates liver inflammation and fibrosis in mice fed high-fat diet

Background

Invariant natural killer T (iNKT) cells have been suggested to play critical roles in a wide range of immune responses by acting in a proinflammatory or anti-inflammatory manner. Nonalcoholic steatohepatitis (NASH) is a chronic liver disease progressing to advanced cirrhosis and hepatocellular carcinoma. Despite the abundance of iNKT cells in the liver, their role in the pathogenesis of NASH remains obscure. Here, we investigated their role in the development of diet-induced steatosis/steatohepatitis.

Methods

We used BALB/c wild-type mice and Jα18-deficient (KO) mice lacking iNKT cells fed either a normal diet or a high-fat diet (HFD). The liver and blood were collected from these mice to examine liver inflammation, steatosis, and fibrosis at the indicated time points.

Results

KO mice fed the HFD, compared with control mice fed the HFD, exhibited a clearly higher serum alanine aminotransferase level and a greater number of hepatic inflammatory foci, although there was no significant difference in hepatic lipid retention between these groups of mice. The HFD enhanced hepatic messenger RNA expression of inflammatory cytokines and chemokines in KO but not in control mice. The HFD also increased the proportion of hepatic CD4 T cells and CD8 T cells that composed hepatic inflammatory foci in KO mice, but not in the controls. Prolonged feeding with the HFD augmented liver fibrosis in KO but not in control mice.

Conclusions

These findings indicate that iNKT cells play a protective role against liver inflammation progressing to fibrosis, but not against steatosis, enhanced by dietary excess fat, suggesting a key role of these cells in NASH pathogenesis.