Kazuhide Ura

UICC and Japanese stage classifications for carcinoma of the pancreas

SummaryThe stage classification (SC) for carcinoma of the pancreas recommended by UICC (UICC-SC) was compared with that of Japan Pancreas Society (JPN-SC) using 229 patients encountered consecutively at the Second Department of Surgery, Nagasaki University School of Medicine over the past 20 yr. By UICC-SC, 51% of the patients belonged to stage IV and 38% to Stage III. By JPN-SC, 82% of the patients belonged to stage IV. Curative resection rates in JPN stage II and III were significantly higher than those in UICC-SC by the chi-squared test. In 60 patients undergoing resectional surgery, postoperative cumulative survival (PCS) curves and rates by each staging criterion (tumor size [T], lymph node metastasis [N], distant metastasis [M], serosal invasion [S], retroperitoneal invasion [Rp], and invasion to the portal venous systems [V]) were calculated by the Kaplan-Meier method. Among these prognostic factors, significant differences in the PCS curves were demonstrated only between Rp(-) and Rp(+), and between V( - ) and V( + ) according to the generalized Wilcoxon’s text. In UICC-SC, the underestimation of these factors leads to a tendency to classify the patients in a less advanced stage than in JPN-SC. JPN-SC is more complex than UICC-SC. Continuing efforts are necessary to establish a more practical, simple, and universal staging system for the disease.

Long-term survivors after operation on carcinoma of the pancreas

SummaryReports of 35 long-term more than five years survivors after resectional surgery which was performed for carcinoma of the pancreas from 1966 to 1980 were collected from major institutions in Japan and analyzed. Male to female ratio was 0.94∶1 and average age was 56 years old. In 34 of the 35, the tumor was located at the head of the pancreas, 32 received pancreatoduodenectomy and two underwent total pancreatectomy. One patient with carcinoma of the tail received distal pancreatectomy. There was no correlation between the size of tumor and the postoperative prognosis. It seems that lymph node metastasis is not an obstacle to long postoperative survivals when they are removed, and also invasion to the pancreatic capsule shows no relationship to prognosis. However, there were no definite or severe invasions to the retroperitoneal tissue, nor to the portal venous system in the 35 patients at all. It is considered that invasion to the retroperitoneal tissues and to the portal venous system may be the most influential factor to the postoperative prognosis.

Solid and Cystic Tumor of the Pancreas in an Adult Male

A solid and cystic tumor (SCT) was located at the head of the pancreas in a 43‐year‐old Japanese male, and pancreatoduodenectomy was performed on the suspicion of papillary carcinoma or cystadenocarcinoma of the pancreas. The lesion, which measured 4.5 X 4.5 X 4.0 cm, was clearly demarcated by connective tissue. The cut surface showed solid grayish‐white areas with central cystic degenerative changes. The solid areas consisted of small round cells proliferating in a small solid or a pseudopapillary pattern. The tumor cells partially invaded the surrounding normal pancreatic parenchyma. Immunohistochemical studies revealed positive staining for alpha‐1‐antitrypsin and neuron‐specific enolase, but no staining for known pancreatic hormones. Moreover, ultrastructural studies showed the absence of zymogen granules and the presence of anullate lamellae and neurosecretory granules. On the basis of these findings, a diagnosis of SCT of the pancreas was established. In order to clarify the histogenesis and biological behavior of the tumor, it is necessary to accumulate and analyze similar cases, an endeavor which in turn will contribute to the successful management of this disease. Acta Pathol Jpn 41: 763‐770, 1991.

Role of bile acids in duodenal migrating motor complexes in dogs

Previous studies have suggested thatenterohepatic circulation of bile acids is essential forregular cycling of duodenal migrating motor complexes(MMCs). The present study was an attempt to clarify the role of bile acids in the enterohepaticcirculation system in initiating duodenal MMCs. Sevendogs underwent total external biliary diversion thatresulted in the loss of MMCs originating from theduodenum. Sodium ursodeoxycholate (6 mg/kg/hr) was thengiven either through the portal vein or a peripheralvein, and motility of the gastrointestinal tract wasserially recorded. When sodium ursodeoxycholate was given either through the portal vein or aperipheral vein during external biliary diversion,duodenal MMCs restarted. The cyclic change in plasmamotilin levels during an MMC cycle as induced by sodium ursodeoxycholate was almost the same as in anormal MMC cycle. Total bile acid concentration in theportal vein changed cyclically with MMC cycles when bileflow was intact but did not change cyclically with MMC cycles restarted by intravenous bilesalt infusion. Bile acid stimulation of putativereceptors existing between the portal vein andintrahepatic bile ducts may be involved in initiatingnormal duodenal MMC cycles.

Hyperbaric oxygen therapy in the treatment of refractory peripancreatic abscess associated with severe acute pancreatitis

SummaryFive patients with peripancreatic abscesses associated with severe acute pancreatitis were treated by hyperbaric oxygen therapy (HBO). In 3 patients, the course after surgical mobilization of the pancreas and drainage of the pancreas bed was complicated by peripancreatic abscesses. HBO was conducted under a pressure of 2.8 atmospheres for two hours dialy. Four of the 5 patients showed a progressive improvement in their condition. In one patient who failed to respond despite seven sessions of HBO, Pseudomonas aeruginosa was isolated from the discharge, and resection of necrotic tissue and drainage were performed. The main effects of HBO were the alleviation of high spiking fever, the improvement of white blood cell count and serum amylase levels, and the reduction of the abscess size. We recognized HBO to be a successful treatment for peripancreatic abscess associated with severe acute pancreatitis and better results were obtained than in cases that did not receive HBO.

Changes in colonic motility in dogs after a resection of the inferior mesenteric ganglion and plexus.

In a curative resection for advanced sigmoid or rectal cancer, an extensive dissection of the regional lymph nodes is generally required. This often necessitates the removal of the autonomic nerves around the inferior mesenteric artery. The present study was done in an attempt to clarify the influence of a neurectomy around the inferior mesenteric ganglion and plexus on the motility of the colon. In eight dogs, we resected the ganglion and plexus around the inferior mesenteric artery, together with an implantation of strain gauge force transducers in various parts of the colon, and 7–10 days later, colonic motility was examined. The percentage of contractile states and contractile forces increased at both the distal colon in fasting dogs, as well as at the middle colon in the late postprandial period. At the distal colon, contractile forces were noted in the early and late postprandial periods. These contractile abnormalities at the middle and distal colon may thus explain the frequent bowel movements or diarrhea often observed after extensive surgery in patients with sigmoid or rectal cancer.

Caroli’s disease associated with hepatolithiasis: A case report and review of the Japanese literature

SummaryA 27-year-old woman was admitted to Nagasaki University Hospital complaining of abdominal pain and fever. Percutaneous transhepatic cholangiography showed multiple cystic dilatations of the intrahepatic bile ducts without stone formation. The illness was diagnosed as a pure type of Caroli’s disease. No surgical intervention was made. Subsequently, the patient suffered repeated attacks of cholangitis, and six years later, computed tomography demonstrated cystic lesions of both lobes of the liver and stones within the cystic lesions of the right lobe. We collected 62 cases of Caroli’s disease reported in the Japanese literature, including our own case. Among them, cholangitis was found in 43.5%, hepatolithiasis in 30.6%, esophageal varices in 17.7% and cholangiocarcinoma in 8.1%. It is difficult to successfully treat Caroli’s disease involving both lobes of the liver. Long-term repeated cholangitis could lead to fibrosis of the liver, hepatolithiasis, portal hypertension and cholangiocarcinoma. Considering the above-mentioned aspects of the disease, careful follow-up studies are required in each case.

Effect of celiac and superior mesenteric ganglionectomy on fasted canine colonic motor activity

The role played by extrinsic nerves in colonic motor activity and motor coordination between the small intestine and the colon in the fasting state was investigated in a canine model. To evaluate motor acivity before and after celiac and superior mesenteric ganglionectomy (CSMG), seven strain gauge force transducers were implanted in the small and large bowels of five dogs. No significant differences were observed in the frequency, duration, cycle, or migration time of bursts of contractions from the colon (BCC), or in the duration of the quiescent state before and after CSMG. When small intestinal phase III activity reached the ileocecal junction before and after CSMG, a characteristic contractile pattern, namely, small intestinal phase III activity followed by BCC, was observed at the ileocecal junction. Before and after CSMG, 84% and 83% of the small intestinal phase III activity, respectively, was transmitted to the colon as BCC after reaching the ileocecal junction. However, only 19% and 18% of BCC before and after CSMG, respectively, followed small intestinal phase III activity. These results led us to conclude that the extrinsic nerves exert little effect on fasting colonic motor activity and motor transmission from the small intestine to the colon.

Cyclic motor activity of the gallbladder maintained in a pylorus-preserving gastrectomy in dogs

The gallbladder has cyclic motor activity (CMA), which is impaired after a conventional gastrectomy. We conducted experiments to determine whether or not a pylorus-preserving gastrectomy (PPG) could maintain gallbladder CMA. Six strain gauge force transducers were implanted into the gastrointestinal tract and gallbladder of six dogs, respectively. The motor activity of the gastrointestinal tract and gallbladder was recorded as a control. PPG was then carried out. The phasic contractions of the gallbladder, which were correlated with the antral contractions in the control state, were synchronized with contractions of the pylorus after PPG. Intravenous administration of CCK-OP (40 ng/kg) induced phasic contractions of the gallbladder at 4.6±0.2c/min in 3 of the 6 dogs with gastric contractions. After PPG, the gallbladder had phasic contractions (4.5±0.2c/m), which were synchronized with the contractions of the pylorus in all dogs regardless of the contractions in the remnant stomach. These findings suggest that gallbladder CMA has a closer relationship with the CMA of the pylorus than with the remnant stomach after PPG. Thus, a preservation of the pylorus at the time of gastric surgery will help in maintaining gallbladder function and coordination with the remnant stomach.

Congenital mesenteric arterio-portal fistula: Report of a case

A male patient with an arterio-portal fistula resulting from a mesenteric arteriovenous malformation, who developed portal hypertension and liver cirrhosis, is presented herein. The malformation was considered to be congenital in origin and its location made any ablative surgical procedure impossible. Such alternative treatments as ligation of the afferent arteries, followed by transarterial embolization were therefore given, but both were unsuccessful. We also present a review of the literatures of mesenteric arteriovenous fistula. Radical surgical approach for the rare entity is proposed. The case reported here as related to mesenteric arteriovenous communications of congenital origin is the seventh such case published, and the first which was ever found to be located in the trunk of the superior mesenteric artery.