Is endoscopic one‐piece mucosal resection essential for early gastric cancer?

Background: Endoscopic mucosal resection (EMR) is widely accepted as a minimally invasive treatment for early gastric cancer (EGC) in Japan. However, the criteria for EMR must be strictly adhered to otherwise patients will miss the chance for additional therapy. We assess the important factor in expanding the indication of EMR. Methods: We investigated 1101 EGCs that had been resected by EMR at the National Cancer Center Hospital (NCCH), Tokyo, Japan, according to the indication recommended by Japanese Gastric Cancer Association (JGCA) and the expanded indication proposed by NCCH. Curability and local recurrence of the EMRs were assessed related to the applied indication and the number of resected specimens. Results: The recurrence rate of non‐evaluable resection was higher than that of evaluable resection (P < 0.0001). Eighty‐three lesions among 772 lesions in the JGCA group were non‐evaluable. Thirty‐seven leisons among 329 lesions in the NCCH group were non‐evaluable. There was no difference in the rate of non‐evaluable resection between JGCA and NCCH groups (P = 0.8329). However, the rate of curative resection was lower in the NCCH group than in the JGCA group (P = 0.0009). In piecemeal resection, there was no difference in the rate of non‐evaluable resection between JGCA and NCCH groups (P = 0.0527). In one‐piece resection, the rate of non‐evaluable resection was lower in the NCCH group than the JGCA group (P = 0.0137). Conclusion: Based on our series of cases, we propose one‐piece resection as a gold standard for EMR because it enables accurate histological evaluation, even in the EMR, according to the expanded indication.     

Microvascular disturbances in the colonic mucosa in antibiotic-associated haemorrhagic colitis: Involvement of platelet aggregation

An ultrastructural study of the colonic mucosa was performed in four patients with antibiotic-associated haemorrhagic colitis and new findings are reported. Colonoscopy was performed and biopsy specimens were obtained within 24 h of the onset of bloody diarrhoea. Colonoscopy demonstrated diffuse oedematous and haemorrhagic mucosa with erosions and white coat. Light microscopy revealed mucosal haemorrhage and inflammatory cell infiltration. Ultrastructurally, platelet aggregation was frequently present in the lumina of colonic mucosal capillaries, causing engorgement of red blood cells in adjacent microvessels. Mild to severe damage was observed in capillary endothelial cells, including discontinuity of basement membranes, gaps between endothelial cells and the destruction of capillaries. There was no evidence of microvascular spasm. In conclusion, our findings suggest that antibiotics directly or indirectly cause microcirculatory disturbances, which result in tissue damage and haemorrhage, in the colonic mucosa.     

Protein Synthesis in Yolk Sac Tumor: Histochemical Studies of Human and Rat Yolk Sac Tumor

Synthesis of various serum proteins, such as albumin, prealbumin, α₁-antitrypsin, transferrin and α-fetoprotein, by human and rat yolk sac tumors was studied by indirect immunofluorescence and immunoperoxidase techniques. These serum proteins were found to be present in the cytoplasm of tumor cells forming the lining of vitelline cysts, as well as Schiller-Duval bodies and vacuolated meshwork on histological sections. Two of these tumors were cultured. Immunopathological studies revealed that albumin, prealbumin, α₁-antitrypsin, transferrin and α-fetoprotein were found in the cytoplasm of these cultured tumor cells. The immunofluorescence of these proteins was also found on the PAS-positive granules, which existed intra- and extra-cellularly.
The ability to synthesize these serum proteins of these tumor cells was not affected by tissue culture and was maintained during subcloning.
It was demonstrated by electron microscope ferritin antibody technique that α-fetoprotein was mainly synthesized on the ribosomes of the rough endoplasmic reticula of rat yolk sac tumor cells.     

Carnitine depletion during total parenteral nutrition despite oral L-carnitine supplementation

Carnitine (CAR) plays an important role in the β-oxidation of fatty acids. Less attention, however, has been paid to CAR compared to other nutrients even in total parenteral nutrition (TPN). To examine CAR metabolism during TPN and the effect of simultaneous oral L-CAR supplementation on CAR levels, the blood CAR level was measured in a 3-year-old boy receiving long-term TPN because of short bowel syndrome. Both the total and acyl CAR in the serum were evaluated under various nutritional conditions including oral supplementation of L-CAR. Low CAR concentrations were observed especially when lipid containing TPN regimens were in place. Oral L-CAR supplementation was not sufficient to restore the low CAR levels in the present index patient even when the dose was increased to 120 mg/kg in accordance with the result of the L-CAR absorption test that revealed poor intestinal absorption of this nutrient. Moreover, a markedly low CAR level was measured during the onset of sepsis in the patient, and the blood CAR was depleted when lipid metabolism was activated by lipid loading or sepsis. To date, the late effects of CAR depletion on child growth have not been well examined. It is recommended that the blood CAR level be maintained at normal levels before any prominent manifestations of the deficiency have developed. The intravenous administration of CAR appears to be necessary to supply a sufficient amount of CAR for patients with severe malabsorption.     

Predictors of early vs. late permanent shunt insertion after aneurysmal subarachnoid hemorrhage

Objective: Numerous studies have identified different predictors for secondary hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH), although predictors regarding timing of the shunt operation have never been reported. Predictors for an early shunt, which was defined as a shunt operation performed ≤30 days after SAH onset, and for a late shunt, performed at >40 days, were investigated.

Methods: A total of 735 consecutive SAH patients admitted to our hospital between 2003 and 2014 who underwent surgery for ruptured aneurysms within five days of onset were retrospectively assessed.

Results: Secondary hydrocephalus developed in 225 patients, including 70 with an early shunt and 96 with a late shunt. Multivariate analysis showed that predictors for secondary hydrocephalus were age ≥70 years, World Federation of Neurosurgical Society (WFNS) grade IV-V, Fisher grade 3–4, intraventricular hemorrhage, anterior cerebral artery aneurysms, and external drainage for acute hydrocephalus (p < 0.05). In the early and late shunt groups, multivariate analysis indicated that early shunt was significantly associated with coil embolization, and late shunt was correlated with middle cerebral artery aneurysms and cerebral infarction due to vasospasm (p < 0.05).

Discussion: The difference in the predictors between the early and late shunts implied that the mechanisms of secondary hydrocephalus differed between the early and late shunt groups. Knowledge of the associated risk factors might help to predict the timing of the shunt operation for early rehabilitation planning in the future.     

World's first magnetic resonance imaging/x-ray/operating room suite: a significant milestone in the improvement of neurosurgical diagnosis and treatment

OBJECT: In February 2006, the magnetic resonance/x-ray/operating room (MRXO) suite opened at the authors' institution. This is the first hybrid neurosurgical procedure suite to combine magnetic resonance (MR) imaging, computed tomography (CT), and angiography within a neurosurgical operating room (OR). In the present paper the authors describe the concept of the MRXO as well as their first 10 months of experience using this suite, and discuss its advantages and limitations. METHODS: In the MRXO suite, the combined OR and angiography (OR-angiography) station is located in the middle of the suite, and the MR imaging and CT scanning stations are each installed in an adjoining bay connected to the OR-angiography station by shielded sliding doors. The surgical, MR imaging, angiography, and CT tables are positioned in order of use. The patient lies on a fully MR imaging- and radiography-compatible mobile patient tabletop that is used to move the patient quickly and safely among the tables in the imaging and operating components of the MRXO suite. RESULTS: The authors performed all interventional procedures safely. The specially designed operating tabletop of the MRXO suite reduced the limitations on neurosurgeons during standard neurosurgical procedures. This hybrid suite helps to provide high-quality intraoperative imaging, greatly reducing the risk of unexpected events during the procedure. CONCLUSIONS: The MRXO suite, which combines OR and imaging equipment, represents a significant milestone in the improvement of neurosurgical diagnosis and treatment and other interventional procedures. Another advantage of the MRXO suite is its cost-effectiveness, which is partly due to its streamlined imaging procedure.