Kiyokazu Toyoda

Synchronous double cancer of the stomach and rectum with situs inversus totalis and polysplenia syndrome.

Situs solitus refers to the normal arrangement of body organs. Situs inversus totalis is a complete mirror image or reverse isomeric form of the thoracic and abdominal viscera. Any arrangement of organs between these two extremes is designated by heterotaxia. Several patterns of vascular and visceral abnormalities are associated with heterotaxia, and two loosely defined syndromes of splenic anomalies (asplenia and polysplenia) are most common. We present the case of a 71-year-old woman with situs inversus totalis and polysplenia syndrome who developed synchronous double cancer originating from the stomach and rectum. Abdominal manifestations were situs inversus totalis combined with multiple lobulated spleen, azygous continuation of the interrupted inferior vena cava, direct drainage of hepatic vein to left atrium, preduodenal portal vein, short pancreas, incomplete rotation of the colon, and malrotation of the intestine. Histologically, gastric cancer was diagnosed as papillary adenocarcinoma and rectal cancer, as moderately differentiated adenocarcinoma. The patient was successfully treated with total gastrectomy for gastric cancer and low-anterior resection of the rectum for rectal cancer.

Melanotic schwannoma of the pancreas: Report of a case

We report a case of pancreatic melanotic schwannoma mimicking an epithelial cystic neoplasm of the pancreas. A 67-year-old Japanese woman underwent routine ultrasonography, which showed a large cystic mass in the head of the pancreas. Contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) showed an inhomogeneous, round cystic mass, which was encapsulated, in the head of the pancreas. We performed pyrolus-preserving pancreatoduodenectomy under the tentative diagnosis of a cystic neoplasm of the pancreas. The histopathologic diagnosis was benign melanotic schwannoma. The patient is now well after 43 months of follow-up. We describe the CT and MRI findings in detail, and review the literature on previously reported cases of pancreatic schwannoma.

Management of massive hemobilia with angiographic embolization

Two cases of angiographic embolization for the management of massive hemobilia due to hepatico-jejunostomy and percutaneous transhepatic biliary drainage are presented. The clinical features are described together with a short review of the literature. In addition to defining the bleeding source, angiography provides an effective and safe alternative to surgery for the control of hemobilia.

Human leucocyte antigen and coronary artery spasm

To elucidate possible genetic links in the pathogenesis of coronary artery spasm, we investigated the frequencies of human leucocyte antigen in 37 patients with variant angina and 236 unrelated healthy controls. We found no significant differences in human leucocyte antigen frequencies between the patients and the controls. These results may suggest that genetic factors in linkage disequilibrium with human leucocyte antigen may not be involved in the pathogenesis of coronary artery spasm.

Identification of carcinoembryonic antigen (CEA) in bile of patients with malignant biliary tract disease

As a diagnostant of malignant hepato-biliary tract disease, carcinoembryonic antigen (CEA) levels in the bile and serum were evaluated in 12 patients with benign and 19 patients with malignant hepato-biliary diseases. Of the 12 patients with benign disease, 3 had a residual choledocholithiasis. CEA levels were determined in 7 patients with cancer of the head of pancreas or of the duodenal ampulla. Bile samples were obtainedvia biliary tract drainage after allowing for sufficient time to exclude the effects of pre-existing bile stasis or inflammation. The average serum CEA levels from 8 patients with benign disease were 1.5±0.23 ng/ml in contrast to 3.3±0.55 ng/ml in 18 with a malignancy (p<0.05). The average CEA levels in bile from 9 patients with benign and 19 with a malignancy were 1.7±0.31 ng/ml and 7.6±1.70 ng/ml respectively (p<0.01). In 3 with residual choledocholithasis, serum and bile CEA levels were 2.0±0.46 ng/ml and 13.1±6.47 ng/ml. The serum and bile CEA levels from 7 patients with cancer of the head of the pancreas or of duodenal ampulla were 2.5±0.32 ng/ml and 8.8±3.3 ng/ml, respectively. Although measurement of both serum and bile CEA levels in patients with hepato-biliary tract disease proved to be useful for differentiation of malignant from benign disease, the high value obtained strongly suggests the presence of a malignancy in addition to the residual choledocholithiasis and cancer of the head of the pancreas or of the duodenal ampulla.

Duodenal ulceration into the cystic artery with massive hemorrhage.

This is a case presentation of a unique cause of intestinal bleeding. A duodenal ulcer eroded into the superficial branch of the cystic artery, causing massive intestinal hemorrhage. The patient, a 76-year-old woman, presented with left upper abdominal and left back pain secondary to cystic lesions in the pancreas body and tail. Stress after operation and complication of leakage of pancreatic juice after distal pancreatectomy with splenectomy and diclofenac sodium administration may have caused a deep peptic ulcer to erode the cystic artery. We performed a transfixing ligation of the bleeding vessel, serosal suture of ulcer of the gallbladder, and simple closure of the duodenal ulcer with covering greater omentum. There were no serious complications after the operation, and the patient made an uneventful recovery.

Preparation and clinical utility of antihuman lymphocyte microsome γ-globulin

To eliminate side effects inherent to the administration of the presently available antilymphocyte serum (ALS), microsomal fractions of lymphocytes have used as the antigen. Antiserum produced using microsomal fraction from mouse thymus cell as the antigen proved to have potent immunosuppressive activity. Subsequently, microsomal fraction from cultured human lymphocytes was used to produce potent immunosuppressive antisera. The antisera thus prepared was found to have a high leucoagglutinin titer. The antihuman lymphocyte microsome γ-glubulin (AHLMG) prepared was administrred to 6 patients undergoing renal transplantation from living donors. Severe rejection episodes and serious side effects such as anaphylactoid reaction and thrombocytopenia were nil. This AHLMG which is devoid of side effects yet retains immunosuppressive activity warrants extended purification.

Occurrence of ANTI-AHLG in renal transplant patients on AHLG (anti-human lymphocyte globulin)

Two patients with kidney transplants were prescribed anti-human lymphocyte γ-globulin (AHLG) as an adjunct immunosuppressive treatment. AHLG was prepared from cultured human lymphocytes as antigen and successive anti-AHLG levels were measured using passive hemagglutination tests during and after the AHLG treatment. Anti-AHLG levels began to increase after 10–14 days of daily AHLG administration. There-after, the levels tends to decrease transiently by the further administration of AHLG. The titer rose again after the discontinuation of AHLG administration reaching a plateau which continued for a considerable length of time. Pretreatment levels were reverted after more than three months. The anti-sheep RBC Ab and anti-horse RBC Ab levels followed the same pattern as that seen with anti-AHLG Ab. The anti-AHLG Ab proved to be specific anti-horse γ-globulin Ab. Alterations in the anti-AHLG levels can thus be used to monitor the optimal dosage and period of administration as well as to predict the anaphylactic reaction due to AHLG treatment. Keeping the anti-AHLG level low is mandatory to maintain good immuno-suppressive conditions yet avoid anaphylactic reactions.