Masahiko Morifuji

Combined Assessment of β- d -Glucan and Degree of Candida Colonization before Starting Empiric Therapy for Candidiasis in Surgical Patients

The purpose of the study was to investigate whether examination for plasma β-d-glucan, a cell wall constituent of fungi, is useful for selecting surgical patients with Candida colonization who would benefit from empiric antifungal therapy. We administered fluconazole to postoperative patients with Candida colonization who have risk factors for candidemia and complained of persistent fever despite prolonged antibacterial therapy. We then analyzed the clinical outcomes regarding the number of sites colonized with Candida spp. and plasma β-d-glucan. Of the 32 patients positive for β-d-glucan, 15 (46.9%) responded to the empiric therapy; only 9% of those who were negative responded (p < 0.01). In the multiple logistic regression analysis, being positive for β-d-glucan was a significant factor predicting response, with an adjusted odds ratio of 12.9 in patients with Candida colonization [95% confidence interval (CI) 2.07–80.73) (p < 0.01). In addition, the number of sites colonized with Candida spp. was a significant factor predicting response, with an estimated exposure odds ratio of 7.57 for those who were colonized at three or more sites compared with those colonized at one site (95% CI 1.20–47.70) (p = 0.031). In patients with Candida colonization, assessment of β-d-glucan was useful for deciding whether to start empiric therapy for suspected candidiasis in surgical patients.

Pancreatic Head Resection With Segmental Duodenectomy for Intraductal Papillary Mucinous Tumors of the Pancreas

Various modifications of organ-preserving pancreatic resections have been performed for intraductal papillary mucinous tumor (IPMT) of the pancreas. The aim of this study was to evaluate usefulness of pancreatic head resection with duodenal segmentectomy (PHRSD), which is one of the organpreserving pancreatic resections for IPMT. Pancreatic head resection with duodenal segmentectomy was indicated for the branch duct type of IPMT. Eight patients underwent PHRSD. The mean operative time was 390 minutes, and the mean blood loss was 1270 ml. Duodenal ischemia was prevented by preserving the duodenal branches of the gastroduodenal artery and the anterior inferior pancreaticoduodenal artery. Complications occurred in four patients: one with pancreatic leak, one with choledochoduodenal anastomotic stenosis, and two with delayed gastric emptying. However, no deaths occurred. The final pathologic diagnosis was adenoma in seven patients and carcinoma in situ in one patient. Six of eight patients had an adenoma with papillary growth in the main pancreatic duct. Postoperative pancreatic endocrine and exocrine functions were satisfactory. All patients were alive without recurrent disease at a median follow-up of 30 months. Pancreatic head resection with duodenal segmentectomy appears to be a useful procedure as an organ-preserving pancreatic resection for the branch duct type of IPMT, because this procedure allows a safe and complete resection of the pancreatic head without ischemia of the common bile duct and the duodenum.

Adenosquamous carcinoma of the pancreas : preoperative diagnosis and molecular alterations

Adenosquamous carcinoma of the pancreas is a rare tumor which has a less favorable prognosis than common ductal cell carcinoma of the pancreas, and a definite preoperative diagnosis of this tumor is quite difficult. We herein report two cases of this rare variant. The patients were a 41-year-old man (patient 1) and a 67-year-old woman (patient 2). Patient 1 had a hypoechoic mass measuring 3 cm in the uncus of the pancreas, while patient 2 had a huge mass, measuring 8 cm, in the tail of the pancreas. Patient 2 was successfully diagnosed preoperatively as having an adenosquamous carcinoma, by cytological examination of the pure pancreatic juice obtained by endoscopic retrograde pancreatic juice aspiration. A pylorus-preserving pancreatoduodenectomy was performed for patient 1, and a distal pancreatectomy with resection of the spleen and the left kidney was performed for patient 2. Subsequent pathological findings of these two tumors revealed adenosquamous carcinoma of the pancreas. K-ras point mutation, p53 overexpression, and telomerase activity in both tumor specimens were detected by the mutant allele specific amplification method, immunohistochemical staining, and telomeric repeat amplification protocol assay, respectively. The two patients died of recurrent disease 5 and 4 months, respectively, after surgery. Cytological examination of pure pancreatic juice is a useful modality for the preoperative diagnosis of this tumor, and frequent molecular alterations may be associated with the poor prognosis of adenosquamous carcinoma of the pancreas.

Usefulness of a 13C-labeled mixed triglyceride breath test for assessing pancreatic exocrine function after pancreatic surgery

BACKGROUND Although the fecal elastase-1 test is a satisfactory pancreatic exocrine function test, breath tests that use stable isotopes have been developed recently as alternatives. We evaluated the usefulness of a (13)C-labeled mixed triglyceride breath test for assessing pancreatic exocrine function after pancreatic surgery. METHODS The breath test and the fecal elastase-1 test were performed on 7 healthy volunteers, 10 patients with chronic pancreatitis, and 95 patients after pancreatic surgery. The breath test was analyzed with isotope ratio mass spectrometry and the cumulative recovery of (13)CO(2) at 7 hours (% dose (13)C cum 7h) was calculated. The fecal elastase-1 concentration was determined immunoenzymatically. RESULTS Both the fecal elastase-1 concentration and the % dose (13)C cum 7h of chronic pancreatitis patients and pancreatic resection patients were less than those of healthy volunteers. In all subjects, % dose (13)C cum 7h correlated with the fecal elastase-1 concentration (n = 112, R(2) = 0.14, P < .01). Accuracy rates for clinical symptoms, including clinical steatorrhea, for the fecal test and the breath test were 62 and 88%, respectively. CONCLUSION The (13)C-labeled mixed triglyceride breath test might be more useful than the fecal elastase-1 test for evaluating pancreatic exocrine function after pancreatic resection.

Duodenal cancer arising from the remaining duodenum after pylorus-preserving pancreatoduodenectomy for ampullary cancer in familial adenomatous polyposis

We herein report a rare occurrence of duodenal cancer arising from the remaining duodenum after pylorus-preserving pancreatoduodenectomy for ampullary cancer in familial adenomatous polyposis (FAP). In this patient, proctocolectomy and ileoanal anastomosis for FAP had been performed 11 years earlier. During the current admission, the patient was diagnosed with adenocarcinoma in the Vater’s ampulla using imaging and pathological examinations. In addition, a pylorus-preserving pancreatoduodenectomy was performed. The tumor was a well-differentiated tubular adenocarcinoma and no other polyps were identified in the duodenum by pathological examination. However, 1 year after surgery, a polypoid lesion measuring 15 * 15 mm was indicated in the remaining duodenum by endoscopic surveillance. This lesion was completely resected by endoscopic mucosal resection and the resected specimen revealed well-differentiated tubular adenocarcinoma in an adenomatous lesion. This report suggests that resection of the total duodenum is essential for duodenal neoplasms in FAP to prevent a recurrence in the remaining duodenum.

Bacterial Translocation: Not a Clinically Relevant Phenomenon in Colorectal Cancer

The aim of this study was to identify the risk factors for bacterial translocation and to determine the clinical significance of bacterial translocation in patients with colorectal cancer. Mesenteric lymph node sampling was performed to identify the presence of bacterial translocation in 75 patients with colorectal cancer undergoing laparotomy. Bacterial translocation was identified in 29 patients (39%), with the most common organism being Escherichia coli (31%). Three factors for bacterial translocation were identified, including a preoperative low peripheral lymphocyte count, metastasis to lymph nodes, and invasion depth (= T3). Stepwise regression analysis, however, selected only = T3 [odds ratio (OR) 4.0, 95% confidence interval (CI) 1.2-13.5]. Altogether, 35% of patients with bacterial translocation developed septic complications, compared with 20% in patients without bacterial translocation. In the multivariate analysis, bacterial translocation was not an independent risk factor for infection, with an OR of 1.8 (95% CI 0.56-5.96). Systemic inflammatory response syndrome developed on the first day in 62% of patients with bacterial translocation, compared with 50% of patients without bacterial translocation. Adjusting for the other factors, bacterial translocation was not a significant risk factor in the occurrence of systemic inflammatory response syndrome after surgery (OR 1.1, 95% CI 0.37-3.29). We concluded that n patients with colorectal cancers bacterial translocation does occur and is increased in patients with deep invasion. However, it appears to be of no clinical significance.

Pancreatic metastasis of dermatofibrosarcoma protuberans.

Dermatofibrosarcoma protuberans (DFSP) is a relatively rare skin tumor that is considered to have intermediate malignancy; it demonstrates frequent local recurrence, but systemic metastasis is rare. We report a 49-year-old woman with pancreatic metastasis of DFSP who underwent total pancreatectomy with partial resection of the portal vein. Except for our patient, only two other cases of pancreatic metastasis of DFSP have been reported in the literature, to our knowledge. Radical resection may be considered for pancreatic metastasis of DFSP when there are no other metastatic lesions.

Mucinous Cystic Neoplasm of the Pancreas with Ovarian-Type Stroma Arising in the Head of the Pancreas: Case Report and Review of the Literature

Although the definition and classification of pancreatic cystic tumors with mucin secretion remain unclear, pancreatic cystic tumors with mucin secretion have recently been divided into two types: mucinous cystic neoplasm (MCN) and intraductal papillary mucinous neoplasm (IPMN) (1, 2). Mucinous cystic neoplasm and IPMN share some common characteristics, including rare incidence, less invasiveness, presence of adenoma–carcinoma sequence, and favorable prognosis. However, there are distinct clinicopathological findings for each type. While IPMN is characterized by cystic dilatation of the pancreatic ducts and a tendency to spread intraductally, MCN usually presents with large unilocular or multilocular cysts lacking communication between the cyst and the pancreatic ductal system. In addition, differentiation between these two pancreatic cystic neoplasms has become much clearer since the presence of ovarian-type stroma was needed in the definition of MCN according to the new classification of exocrine pancreatic tumors by the World Health Organization (WHO) (1). According to the previous reports concerning MCN with ovarian-type stroma, MCN occurred exclusively in middle-aged women and usually arose in the body or tail of the pancreas (3–9). Mucinous cystic neoplasms arising in the pancreatic head are very rare. We report here a rare case of MCN with

Double Intussusceptions in the Small Intestine Caused by Metastatic Renal Cell Carcinoma : Report of a Case

Renal cell carcinoma (RCC) may metastasize to almost any organ, but it is unlikely to be a direct cause of intussusception. We report a case of double enteric intussusceptions caused by metastatic RCC in a 64-year-old man. The patient presented with intermittent abdominal pain and diarrhea 11 years after undergoing a radical nephrectomy. Abdominal computed tomography (CT) showed two enhanced masses with the “target” sign, suggesting enteric intussusceptions. We performed partial enterectomy, and histological examination confirmed that the tumors had originated from RCC. To our knowledge, this is the first report of metastases from RCC manifesting as synchronous intraluminal polypoid tumors serving as the lead points of two intussusceptions in the small intestine. Thus, the possibility of multiple tumor metastases in the small intestine, with or without intussusceptions, should be considered in patients with recurrent RCC.

Successful pre-operative diagnosis of malignant intraductal papillary mucinous tumor of the pancreas by detecting telomerase activity.

SummaryBackground. Pre-operative differential diagnosis between and malignant intraductal papillary mucinous tumor (IPMT) of the pancreas is markedly difficult by imaging examination. In recent years, telomerase activity has been reported to be detected only in malignant tumors. Methods. A 52-yr-old man with abdominal pain was diagnosed with a IPMT through imaging examination. Telomerase activity of the pure pancreatic juice, which was obtained pre-operatively by endoscopic retrograde pancreatic juice aspiration (ERPJA), was analyzed by telomeric repeat amplification protocol (TRAP) assay. Results. Telomerase activity was detected in the pure pancreatic juice of the patient, who was diagnosed with a malignant IPMT. A pylorus-preserving pancreatoduodenectomy was performed, and subsequent pathological findings revealed the tumor to be adenocarcinoma in adenoma with papillary growth. Conclusion. Detection of telomerase activity of the pure pancreatic juice might be useful to distinguish benign from malignant IPMT pre-operatively.