[Case of malignant schwannoma in the posterior mediastinum].
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Biomedical subjects
Publications and source records attributed to K Inokuchi.
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Among colorectal cancer patients operated at the 2nd Department of Surgery, Kyushu University Hospital between 1974 to 1980. 6 developed this cancer after partial or total gastrectomy for gastric cancer or ulcer. The interval between the gastric operation and colorectal surgery ranged from 15 months to 17 years. The colorectal cancers arose in the transverse colon (1) the sigmoid colon (2), there were 3 rectal cancers. Therefore, not only the occurrence of recurrent or primary cancer in the remnant stomach, but also the occurrence of colorectal cancer should be monitored carefully after partial or total gastrectomy for gastric cancer or ulcer.
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The nucleotide sequence of the ompF gene coding for a major outer membrane protein of Escherichia coli K-12 has been determined and the amino acid sequence of the OmpF protein was deduced from it. The OmpF protein contains 340 amino acid residues, and is produced from a precursor having 22 extra amino acid residues, the signal peptide, at the amino terminus. The expected secondary structure of the OmpF protein had a high beta-sheet content with a low alpha-helix content. The promoter region and the transcription termination region of the ompF gene had a significantly high AT content, while the AT content of the coding region was about the same as the average AT content of the E. coli chromosome. Following the termination codon, a typical rho-independent transcription termination signal was observed. The codon usage in the ompF gene was highly nonrandom; the codons preferably utilized are those recognized by the most abundant species of isoaccepting tRNAs or those, among synonymous codons recognized by the same tRNA, that can interact more properly with the anticodon.
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The effects of doxorubicin (Adriamycin) on regenerating liver were studied after two-thirds hepatectomy in rats. In Group I, standard two-thirds hepatectomy was performed. Doxorubicin in a dose of 2 mg/kg (Group II) and 6 mg/kg (Group III) was given intravenously immediately after the same hepatectomy. In Group IV, 6 mg/kg doxorubicin was given after sham operation. Animal survival, body weight restoration, wet weight and mitotic activity of remnant livers, and serum albumin concentrations were examined 1-14 days after operation. The survival rates were 95.5% in Group I, 76.8% in Group II, 10.3% in Group III, and 96.7% in Group IV. Although there were no differences in the residual liver weights among the hepatectomized groups, treatment with doxorubicin induced substantial, dose-dependent suppression and delay of liver cell division. Serum albumin levels dropped considerably in hepatectomized, doxorubicin-treated rats. Light microscopy showed degenerative changes with a single cell necrosis of hepatocytes in Group III. Death among rats hepatectomized and treated with doxorubicin was considered to be mainly due to the failure of residual livers since albumin synthesis was impaired and no marked changes were seen in vital organs other than the liver. For patients with hepatoma, the present results may indicate that the administration of adjuvant chemotherapy with doxorubicin, when necessary immediately after hepatectomy, should be performed with great care. In the absence of such necessity, doxorubicin should be withheld until life-sustaining liver regeneration has taken place.
Serum activities of lysosomal enzymes beta-glucuronidase and acid phosphatase were serially estimated in 14 patients with and without cirrhosis of the liver who underwent 40% to 80% hepatic resection. Substantial increases in enzyme activities were observed two to eight weeks after operation in ten of 11 patients who did not suffer from postoperative liver failure. Regeneration of the residual livers was almost satisfactory in all 11, as evidenced by clinical, roentgenologic, and histologic findings. In three patients with advanced cirrhosis who died of hepatic failure 21 to 39 days after extensive hepatic resection, there was neither the enzymatic reaction nor evidence of regeneration of the liver remnants. In the light of this study and our previous experimental studies, serial determination of the lysosomal enzyme activities in blood is probably a beneficial biochemical index for detection of progressive hepatic regeneration.
The value of the cough reflex and its pressure and flow in the immediate postoperative period was measured in patients who underwent subtotal oesophagectomy and reconstruction for oesophageal cancer and other thoracic surgery. Twenty-two patients with subtotal oesophagectomy and reconstruction were found to have an extensive reduction in cough reflex and force, compared with those who had undergone pulmonary lobectomy. Damage to the vagal nerve caused by dissection of the paratracheal lymph nodes, and injury to the diaphragm during operation for oesophageal cancer appeared to be responsible for the inability to cough. It was of interest that the patients who showed a high value of cough reflex and force in the immediate postoperative period had few pulmonary complications. The postoperative measurement of cough ability may be a useful indicator for safe extubation of the intratracheal tube, as a means of preventing pulmonary complications after thoracic surgery. Continuous mechanical ventilation and frequent suction to remove retained secretions are strongly recommended for the patients who are unable to cough properly.
Serum activities of two lysosomal enzymes, beta-glucuronidase and acid phosphatase, were estimated in 66 patients with liver cell carcinoma, 10 with secondary liver cancer, 14 with cirrhosis of the liver, and 9 normal controls. A substantial increase in the enzyme activities was found in patients with liver cell carcinoma but not in those with secondary liver cancer. The degree of the enzyme elevations paralleled the stage of hepatoma. Although the serum activities of both enzymes were also elevated in patients with liver cirrhosis, the elevations were significantly higher in hepatoma than in liver cirrhosis. Possible mechanisms for the elevation of serum lysosomal enzyme activities in hepatoma are discussed, but further studies are necessary to elucidate the biological and clinicopathological significance of estimating serum lysosomal acid hydrolases in patients with primary liver cell carcinoma.
Two forms of effective, supplemental, intraoperative chemotherapy for carcinoma of the esophagus have been devised, i.e., Bleomycin (BLM)-Spongel aimed at prevention of a local recurrence and trans-lymph-nodal administration of BLM for prevention of recurrence in the intramediastinal lymph nodes. Fifty-one patients given one or both of these local cancer chemotherapy had a lower incidence of local and/or lymph node recurrence in twelve months after surgery than did the controls. As both procedures are simple and there are few adverse effects, further application of this form of chemotherapy is warranted.
Effectiveness of prophylactic extensive lymph node dissection (PELD) plus postoperative long term combination chemotherapy (PLCC) for patients with curatively resected gastric carcinoma was assessed in terms of the degree of serosal invasion and lymph node metastasis. Either the Group 1 and Group 2 lymph nodes were eradicated by PELD. PLCC included intermittent intravenous administration of mitomycin C (0.4 mg/kg intraoperatively followed by 0.2 mg/kg every 3 months) and oral administration of Tegafur (600-800 mg/day) and PSK (3.0 g/day), an immunostimulator, for as long a period as possible. PELD alone resulted in a cure when the malignancy was confined to the mucosal and muscular layers of the stomach as well as to the Group 1 lymph nodes. In cases when the carcinoma involved the serosa and/or the Group 2 lymph nodes, the 5 year survival rate was about 55 per cent the PELD and PLCC groups, such being significantly higher than about 27 per cent in the PELD alone group. Therefore, PELD plus PLCC is highly effective for advanced gastric carcinoma, under a condition of curative resection.
Two groups of patients with esophageal carcinoma were studied retrospectively: Group I as controls, included 50 patients who underwent esophageal resection mainly combined with preoperative radiation therapy during the period from 1965 to 1971; and Group 2 included 83 patients who were given the same treatment plus post-operative radiation and adjuvant postoperative long-term cancer immunochemotherapy during the period from 1972-1979. The one, two and five-year survival rates were 32.0, 14.0 and 12.0 per cent in Group 1, and 55.4, 35.8 and 21.5 per cent in Group 2 respectively. There were significant differences in one-year (p less than 0.02) and two-year (p less than 0.05) survival rates between the two groups. We also found that adjuvant therapy was effective in patients with no lymph node metastasis, while it was less effective in those with lymph node metastases.
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Postoperative long-term cancer chemotherapy (PLCC) with a combination of Mitomycin-C, Tegafur and PSK (an immunostimulant) was applied to non-curatively resected cases with stage IV gastric cancer (invading the adjacent organs and/or with metastasis to the liver, peritoneum, and/or distant lymph nodes). This approach has a significant life-prolongation effect. The two-year survival rate was 16.8 per cent in the PLCC group, such being higher than 6.7 per cent and 1.7 per cent in MMC and no chemotherapy groups (p less than 0.05). 50 per cent survival periods in those with liver metastasis were 8.3 months in the PLCC group, such being longer than 5.2 and 2.8 months in MMC and no chemotherapy groups (p less than 0.002) respectively. Combination therapy of PLCC and intra-arterial infusion of 5-FU through the proper hepatic artery prescribed for 8 patients with liver metastasis resulted in a 3-month prolongation of 50 per cent survival periods, compared with PLCC alone (p less than 0.05). In those with peritoneal dissemination the rate was 10.5 months in the PLCC group, that is longer than 6.5 months in the MMC group (p less than 0.02). In cases of invasion to other organs plus distant lymph node metastasis, the time was 11.0 in PLCC and 7.0 months in MMC groups (p less than 0.05). Thus, PLCC is a palliative approach for non-curatively resected carcinoma of the stomach.
A clinical review of 400 prosthetic arterial reconstructions, carried out in the Second Department of Surgery of Kyushu University Hospital during a period from 1965 to 1981, revealed 10 graft infections (2.5 per cent). There were two out of 120 abdominal aneurysms (1.7 per cent) and 8 out of 260 aorto-femoral occlusive diseases (3.1 per cent). The contributing factors included intraoperative contamination with duodenal juice during surgery for abdominal aneurysms ruptured into the duodenum (2 cases), minor hematoma and/or lymphorrhoea at the groin or lower abdominal wall (5 cases), wound infection (1 case), compression necrosis of the sigmoid colon by the implanted graft (1 case) or perityphlitic abscess due to a perforating appendicitis (1 case). Bacteriologic examination revealed a predominance of a variety of staphylococcus at the groin or lower abdominal wall and E. coli in the abdominal cavity. Four patients expired. Limb amputation had to be done in 2, and 4 were cured. In the management of infected graft at the groin or lower abdominal wall, we used with success a skin sliding closure technique after continuous wound lavage in 3 patients.
In attempts to predict the recurrence of gastric cancer, postoperative changes in serum carcinoembryonic antigen (CEA) levels are monitored in our clinic by radioimmunoassay (Dainabot, Japan). Recurrences are suspected when serum CEA levels are 4 ng/ml, in the postoperative period. Out of 34 patients in whom there were increases in serum CEA, 18 were confirmed to have a recurrence and 15 of these 18 patients were assessed accurately by serial postoperative levels of CEA, two patients died of a recurrence after elevation of serum CEA levels. Thus, recurrence was predicted in 17 out of 34 patients (50 per cent) and in 12 out of 17 patients there was a metastasis to the liver. In 14 out of 34 patients there are no signs of recurrence 9 to 25 months after serum CEA elevations.
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We have clinically evaluated Russian and American stapling devices used for esophageal reconstruction and compared the results following stapled anastomosis with those following hand-sutured procedures, both performed by the same surgeon. With the Russian stapler, anastomoses performed in 17 patients with carcinoma of the thoracic esophagus resulted in only one (5.9%) anastomotic leak; in 12 hand-sutured anastomoses and in 11 anastomoses done with an American stapler, no anastomotic complication occurred. Thus, a long gastric tube with good blood supply is of paramount importance, and if the technical details of surgical stapling can be overcome, a stapled anastomosis appears to be as safe as a manual suturing for patients undergoing esophageal reconstruction.