Kazunori Furuta

A simpler and more reliable technique of pancreatojejunal anastomosis

We herein describe the technical aspects of our method for end-to-side style pancreatojejunal anastomosis which we have been using when performing the Whipple procedure without any anastomotic complications. The method is simple and can be applied wherever an end-to-side pancreatojejunal anastomosis is required. It consists of three steps: First, a drainage tube is inserted into the pancreatic duct. Second, a direct anastomosis between the pancreatic duct and the mucosal layer of the jejunal loop is performed. The third step, which is the unique aspect of our method, is an approximation of the jejunal wall and the pancreatic stump by a one-layer suture technique that allows us not only to reduce the number of sutures but also to eliminate some of the sophisticated manipulations required by other methods. The results of our clinical experience have indicated that the present method may be comparable in terms of technical reliability to other existing methods.

Thoracoscopic splanchnicectomy for the relief of intractable abdominal pain

Video-thoracoscopic transthoracic splanchnicectomy has been applied to patients in the end stage of pancreas cancer who had intractable pain mediated through the splanchnic nerve in the left upper quadrant. The procedure is performed under general anesthesia in a right hemilateral position. Following the establishment of access to the thoracic cavity, the left splanchnic nerve is cut off at the level immediately above the aortic hiatus, through a small opening made in the pleura between the descending aorta and the vertebrae. All patients had immediate and complete relief of pain postoperatively. Only a transient drop in the mean arterial pressure was observed immediately after cutting off the nerve. No other detrimental effect of the procedure on the general condition was observed. No patients developed postoperative complications. The present method may, thus, be a treatment of choice directed toward the relief of intractable abdominal pain in selected patients with pancreatic cancer.

Experimental study on liver regeneration after simultaneous partial hepatectomy and pancreatectomy

In this study, we performed hepatectomy and pancreatectomy to assess the physiological contribution of the pancreas, especially in terms of endocrine function to hepatic regeneration. Group 1 Wistar rats underwent 70% hepatectomy and group 2 rats underwent 70% hepatectomy plus 50% pancreatectomy. The time course assessment of liver regeneration rates obtained by Fishbacks formula demonstrated a difference in rates between the two groups as early as day 3 or day 7 after surgery. Since levels of both PCNA-positive cells and serum transforming growth factor-alpha (TGF-alpha) were significantly higher in the hepatectomy only group, we could prove the difference of liver regeneration between the two groups. We have concluded that pancreatectomy retards the liver regeneration initiation processes occurring from 24 h to 3 days after evisceration. Glucagon-insulin molar ratios most significantly differed between the two groups 3 days after evisceration in the present study. This result was due to increased glucagon level of group 2 at day 3 after evisceration. Our findings suggest that 50% partial pancreatectomy inhibits the rate of hepatic regeneration, thereby altering the supply of pancreatic hormones, especially glucagon.

Extraovarian peritoneal serous papillary carcinoma showing complete remission after treatment with cisplatin

Abstract Extraovarian peritoneal serous papillary carcinoma is a rare disease in women that arises from extraovarian peritoneum with müllerian potential. It shows histopathological findings identical to those of ovarian serous carcinoma. At diagnosis, this disease usually exhibits peritoneal carcinomatosis, but evidence of a primary site is lacking. We experienced a case of extraovarian peritoneal serous papillary carcinoma in a 72-year-old woman who complained of abdominal distension and soon after developed bowel obstruction. Although we failed to perform any effective surgical procedure at laparotomy, because the cancer was extremely advanced, treatment with cisplatin resulted in rapid reduction of the tumor, and, finally, in its complete disappearance. Cisplatin was administered only three times, and the total dose was 300 mg. The patient is still alive and clinically free of recurrence 32 months after her first visit to our hospital. In this report we describe her clinical course, and discuss the diagnosis and treatment of this disease, and the usefulness of tumor markers for monitoring it.

Cavernous transformation of the portal vein coinciding with early gastric cancer and cholelithiasis

A 71-year-old man who developed jaundice with a high-grade fever was admitted to our hospital. The episode was ascribed to cholecysto-choledocholithiasis. In the preoperative evaluation, a cavernous transformation of the portal vein and an early gastric cancer were found. The patient thereafter underwent an operation for those pathologies after the endoscopic removal of a choledochal stone; cholecystectomy, and a distal gastrectomy with regional lymph node dissection for gastric cancer. The proposed procedures of gastrectomy and cholecystectomy were completed without any major difficulty because no markedly enlarged collateral veins were found in the area where the regional lymph node dissection was carried out. Thanks to advances in imaging modalities, an asymptomatic cavernous transformation of the portal vein coinciding with gastric cancer such as that seen in the present case may be increasingly encountered in the future. The greatest caution, however, needs to be exerted at operation to minimize any unexpected bleeding and to avoid any interruption of the porto-portal shunts in such cases. Further, the reestablishment of the portal blood supply to the liver might be required in advanced cases of gastric cancer, where regional lymph node dissection may necessitate skeletonization of the hepatoduodenal ligament for curative purposes.

Regional vascular occlusion of the liver by radiological intervention for the treatment of hepatocellular carcinoma

We believe that regional vascular occlusion of the liver is more effective for the treatment of hepatocellular carcinoma (HCC) than transcatheter arterial embolization or percutaneous ethanol injection. We report a patient with HCC in whom regional vascular occlusion by means of radiological intervention was successfully performed. A 68-year-old man was admitted to our hospital because of a HCC measuring 2 cm in diameter in segment VIII (S8). For treatment, we initially performed subsegmental vascular occlusion by simultaneous transcatheter arterial embolization and percutaneous transhepatic portal-venous embolization. Both the arterio-and the portograms taken immediately after the procedure demonstrated the lack of arterial and portal blood supply to S8. Subsequent evaluation of the liver by computed tomography and magnetic resonance imaging suggested that S8 had become completely infarcted and the segment appeared wedge-shaped. This finding was histologically confirmed when hepatic subsegmentectomy was performed 5 weeks later. The results in this patients confirmed the results reported by Nakao et al. in 1986 (Hepatocellular carcinoma: Combined hepatic arterial and portal venous embolizationRadiology 161:303–307) suggesting that regional vascular occlusion of the liver was safe and that the effectiveness was comparable to that of hepatic resection.

Focal nodular hyperplasia of the liver: A patient with two concurrent lesions that manifested different behavior on radiographic imaging tests

Focal nodular hyperplasia (FNH) of the liver is a relatively uncommon pathology, with only 68 cases having been documented to date in Japan. Here, we describe an interesting case; the patient had two concurrent lesions of FNH in segments three (S3) and five (S5), respectively. The two lesions differed from each other in their behavior on various radiographic imagings, i.e., computed tomography, magnetic resonance imaging, and hepatic angiography, leading to a misdiagnosis of hepatocellular carcinoma for the S3 lesion. The patient underwent left lateral hepatic resection, along with excision of the S5 lesion. Histological examination confirmed that these two lesions were FNH. Retrospective assessment of the correlation between the radiographic imagings and the morphological architecture suggested that the architectural differences between the two lesions (i.e., that, in the S3 lesion, the central scar was more developed than in the S5 lesion and was more prominent in the periphery than in the central area of the lesion) had contributed to the misdiagnosis.