Kazuaki Hazama

Distal Pancreatectomy With En Bloc Celiac Axis Resection for Locally Advanced Pancreatic Body Cancer: Long-term Results

Objective:To analyze the long-term results of distal pancreatectomy with en bloc celiac axis resection (DP-CAR), a newly designed extended surgical procedure for locally advanced cancer of the pancreatic body. Summary Background Data:Pancreatic body cancer often involves the common hepatic artery and/or the celiac axis and is regarded as an unresectable disease. We previously reported the feasibility and safety of DP-CAR in 10 patients and 3 preliminary cases; however, the long-term results are unknown. Methods:Between May 1998 and September 2005, 23 patients underwent DP-CAR. No reconstruction of the arterial system was required because of early development of the collateral arterial pathways via the pancreatoduodenal arcades from the superior mesenteric artery. We routinely used preoperative coil embolization of the common hepatic artery to enlarge the collateral pathways. Results:The postoperative mortality rate was 0%, despite a high morbidity rate (48%). The chief postoperative complications were pancreatic fistula and ischemic gastropathy. Contrary to expectations, postoperative diarrhea was mild. Preoperative intractable abdominal and/or back pain in 10 patients was completely alleviated immediately after surgery. The surgical margins were histologically negative in 21 patients (91%). The estimated overall 1- and 5-year survival rates were 71% and 42%, respectively, and the median survival was 21.0 months. The sites of recurrence were the liver in 6 patients and local recurrence in 2. Conclusions:DP-CAR offers a high R0 resectability rate and may potentially achieve complete local control in selected patients. The persisting early hepatic recurrence may indicate DP-CAR for the treatment of less advanced disease.

Primary Small Cell Carcinoma of the Common Bile Duct, in Which Surgical Treatment was Performed After Neoadjuvant Chemotherapy: Report of a Case

Primary small cell carcinoma of the hepatobiliary tract is rare. Most cases occur in the gallbladder or in the ampulla of Vater, and such cases in the common bile duct (CBD) are extremely rare. We herein report a case of small cell carcinoma arising in the CBD. In this case, neoadjuvant chemotherapy followed by pylorus-preserving pancreaticoduodenectomy showed an excellent response. To our knowledge, this is the first reported case of small cell carcinoma of the CBD in which a radical resection was performed after successful neoadjuvant chemotherapy.

Improved healing of small-caliber, long-fibril expanded polytetrafluoroethylene vascular grafts by covalent bonding of fibronectin

PurposeTo evaluate the intermediate performance of small-caliber, long-fibril expanded polytetrafluoroethylene (ePTFE) vascular grafts pretreated with covalent bonding of fibronectin in dogs.MethodsSmall-caliber (4 mm), long-fibril (60 µm), ePTFE vascular grafts, 10 cm in length, were pretreated by covalent bonding of fibronectin. Bilateral iliac grafting was done in dogs using a fibronectin-bonded graft on one side and a nonbonded control graft on the other side. The grafts were retrieved 12 weeks after implantation, and subjected to histomorphometric analysis.ResultsAlthough the patency rates of the fibronectin-bonded and control grafts were the same (3/7, 43%), the fibronectin-bonded grafts showed almost complete neointimal healing, whereas the nonbonded control grafts showed only partial neointimal healing, proximally and distally.ConclusionsSmall-caliber, long-fibril ePTFE vascular grafts with covalent bonding of fibronectin achieved almost complete neointimal healing by the time of retrieval at 12 weeks. This indicates that, with further modifications, our new technique for covalent bonding of fibronectin has great potential in the development of small-caliber arterial prosthetic grafts.

Large-cell neuroendocrine carcinoma in the thymus

Large-cell neuroendocrine carcinoma in the thymus is a rare cancer that is more aggressive and leads to a poorer prognosis than other thymic epithelial tumors. A 67-year-old woman presented with an anterior mediastinal mass in the thymus. Histological examination after thymectomy revealed large-cell neuroendocrine carcinoma in the thymus. Although the patient received postoperative chemotherapy and radiotherapy, a distant relapse was detected 6 months after the surgery. We reviewed nine cases of this rare cancer that have been reported in Japan. There is no evidence of to support postoperative therapy for large-cell neuroendocrine carcinoma in the thymus. However, it is essential to accumulate and study these cases to understand this disease and prolong patient survival.

Heterotopic gastric mucosa in the gallbladder: Report of two cases

This report presents two cases of heterotopic gastric mucosa in the gallbladder. In case 1, the patient was a 43-year-old man who presented with diarrhea and fever. Abdominal ultrasonography showed a sessile polypoid lesion in the body of the gallbladder that grew over 2 months. Gallbladder carcinoma was suspected and a cholecystectomy was performed. Examination of an intraoperative frozen specimen of the elevated lesion in the body of the gallbladder suggested a gallbladder carcinoma invading the subserosal layer. A bile duct resection and regional lymph node dissection were performed. However, the postoperative permanent sections revealed heterotopic gastric mucosa in the gallbladder. Case 2 was an 80-year-old man. Screening abdominal ultrasonography revealed a sessile polypoid lesion in the gallbladder. This lesion was correctly diagnosed as heterotopic gastric mucosa in the gallbladder by the intraoperative frozen examination. The pertinent literature on this topic is reviewed.

Relationship between fibril length and tissue ingrowth in the healing of expanded polytetrafluoroethylene grafts.

PurposeTo determine whether fibril length is correlated with graft healing as well as cellular and capillary ingrowth in a canine carotid implantation model.MethodsExpanded polytetrafluoroethylene (ePTFE) vascular grafts with three different fibril lengths (30, 60, and 90 µm) were implanted into the carotid artery in dogs. They were retrieved 4 weeks later, and subjected to histomorphometric analysis.ResultsEndothelial healing was best in the 60-µm grafts. Not only cellular ingrowth but also capillary ingrowth was most evident in the 60-µm grafts, followed by the 90-µm grafts and then the 30-µm grafts.ConclusionBetter endothelial healing of ePTFE vascular grafts is correlated with more cellular and capillary ingrowth, but more cellular and capillary ingrowth is not correlated with longer fibril length or higher air porosity.

A new, simple stapling technique for pulmonary emphysema : its effects and safety for improving respiratory function

PurposeWe performed lung volume reduction surgery (LVRS) in an experimental model using a simple stapling technique (SST) for pulmonary emphysema. The technique uses a stapler to isolate the affected lung from the remaining lung instead of removing it. We performed the present experiment using dogs to study the effects and safety of LVRS using the SST.MethodsPulmonary emphysema was induced in 12 dogs with papain. They were divided into three groups: those operated on with SST composed the operation (Op) group; those receiving an experimental thoracotomy composed the sham-operation (Sham-op) group; and those not operated on composed the nonoperation (Non-op) group. Respiratory function was compared among the groups before induction of emphysema (baseline), after induction of emphysema (preoperation), and at 8 weeks after the operation (postoperation Op and Sham-op groups only). The lung was removed and histologically examined 8 weeks after the SST operation.ResultsIn the Op group, alteration in forced expiratory volume (FEV) 0.5%, airway resistance (Raw) and specific airway conductance (sGaw) showed significantly favorable results. Histologically, the isolated area was widely replaced by fibrous tissue with numerous blood vessels in the circumference in the Op group; no signs of infection such as polykaryoleukocytes or microabscesses were observed in any of the samples.ConclusionThe LVRS for pulmonary emphysema using a simple stapling technique improved the expiratory flow and alleviated airway resistance. The isolated remaining lung was well organized without any infectious events or secondary adversity, thus demonstrating the safety of this technique. From these results, this technique is therefore suggested to be effective and applicable to clinical use.

A Case Report of Perfornated Intestinal Tuberculosis.

近年, 我が国における結核患者数は増加傾向を示しており, それに伴い腸結核症に遭遇する機会も増加している. 今回, 我々は穿孔を来した腸結核症の1例を経験したので報告する. 症例は54歳の男性で, 腹痛を主訴に当院救急外来を受診した. るいそう著明で, 胸部単純X線にて両側上肺野に侵潤影および一部に空洞形成を認めた. また, 腹部は板状硬であり汎発性腹膜炎と診断し同日, 緊急手術を施行した. 小腸から大腸にかけて合計26か所の多発性輪状潰瘍を認め, うち1か所が穿孔していた.穿孔部腸管の切除を施行し全身管理を行ったが術翌日に突然の心停止を来たし死亡した. 部検の結果, 肺結核症, 腸結核, および粟粒性結核症が確診された.今後, 結核患者にあっては急性腹症の鑑別疾患として腸結核穿孔も念頭に置く必要があるものと考えられた.