Masakazu Nobori

Evolution of Mirizzi syndrome with biliobiliary fistula

The mechanisms of fistula formation were analyzed in eight patients with Mirizzi syndrome with biliobiliary fistula. The fistula was type 1 in three patients and type 2 in five, according to the Corlette-Bismuth classification. The apparent mechanisms of fistula formation include inflammation of the gallbladder, its subsequent fusion to the bile duct, and increase in the internal pressure due to either contraction of the gallbladder or multiple stones. However, no predisposing conditions other than a longstanding history of cholelithiasis have been suggested. Differences in the type of fistula are considered to be due to the mode of fusion of the gallbladder to the bile duct, and the size of the perforation, which is apparently determined by the area in contact with the stone.

Does bile spillage during an operation present a risk for peritoneal metastasis in bile duct carcinoma

Whether bile spillage during operation presents a risk for peritoneal metastasis in the treatment of bile duct carcinoma was studied in 15 patients (12 with bile duct cancer, 3 with cancer of the papilla of Vater) who had all undergone a pancreatoduodenectomy. Preoperative bile was sampled through a percutaneous transhepatic biliary drainage catheter. Nine patients with bile duct cancer and one with cancer of the papilla of Vater showed positive bile cytology. The operative bile was obtained at the hepatic duct stump after a resection of the tumor-bearing bile duct. The operative bile in 10 patients with positive preoperative bile was found to be positive, while that in the five patients with negative preoperative bile was negative. Thus, the specificity of operative bile was identified as 100%. Moreover, in five patients with preoperative positive bile, saline irrigation of intrahepatic bile duct after a full recovery of hepatic bile revealed cancer cells to remain in the intrahepatic biliary trees. The viability of preoperative bile was 61%–97% with 104–2.4×105 tumor cells, whereas there was a 41%–97% viability with 7.6×104–10.4×105 tumor cells in the operative or irrigated bile. Accordingly, the patients with preoperative positive bile are thus suggested to be at high risk of inducing peritoneal metastasis due to the inadvertent spillage of hepatic bile at the time of resection of a bile duct tumor.

Anastomotic recurrence at hepaticojejunostomy in a long-term survivor of bile duct carcinoma: Report of a case

A rare case of autopsy-proven recurrence 10 years after a radical resection for lower bile duct carcinoma is herein reported. The subject is a 53-year-old man who underwent a curative resection of distal bile duct carcinoma with pancreatoduodenectomy in 1981. The lesion was a 1.0 X 1.5 X 1.0 cm well-differentiated papillotubular adenocarcinoma invading the fibromuscular layer of the bile duct with a slight infiltration to the lymphatics but without any extension to the vessels, nerves, connective tissues, or nodes. The patient demonstrated a recurrence 10 years after the initial operation and died 4 months later. An autopsy revealed a 2.0 X 2.5 X 1.6 cm mass at the anastomotic site of hepaticojejunostomy without any distant metastases. Although a late anastomotic recurrence after more than 10 years is unique, this case highlights the difficulty of the operative eradication of bile duct carcinoma. As a result, all possible maneuvers either during or after operation to promote the prophylaxis of recurrence are warranted.

Allotransplantation of the pancrease in dogs

Abstract En block transplantation of the pancreas and duodenum was performed in 30 pancreatectomized dogs, 10 of which served as a control group and the remaining 20 as the azathioprine group. The latter were orally administered (6 mg. per kilogram) azathioprine every day. The former group lived an average of 10 days; and the latter, 22 days. Rejection was a cause of death in 6 of the control group and in 6 of the azathioprine group. In 5 of these 12, however, the last fasting blood glucose level was over 150 mg. per deciliter, suggesting that hyperglycemia is not an initial sign of rejection but rather its terminal sign. Histological study revealed that acute rejection resembling acute pancreatitis was a phenomenon observed in the control group, while chronic rejection manifested by interstitial fibrosis was characteristic of the azathioprine group. Azathioprine is effective in suppressing the acute rejection process but is unable to prevent fibrotic process.

A case of an aortocolic fistula occurring 27 years after aorto-femoral bypass surgery, treated successfully by surgical management

The secondary aortoenteric fistula (AEF) is a rare but grave complication of aortic reconstructive surgery. We report herein a case of an aortocolic fistula which occurred 27 years after an aortofemoral bypass. A 69-year-old man was admitted to hospital following a sudden episode of melena. He had undergone aortofemoral bypass surgery with a prosthetic graft 27 years previously for occlusive disease of the right external iliac artery. Colonofiberscopy, CT scan, and angiography were performed, and an aortocolic fistula due to an aortic anastomotic pseudoaneurysm was diagnosed. The first-stage operation, being resection of the previously implanted graft, right hemicolectomy, and aortic stump closure were carried out with concomitant axillo-right femoral bypass. A femoro-femoral crossover bypass was performed in the second stage and the patients recovery followed uneventfully. This case constitutes the longest postoperative interval for an AEF recorded in the English literature.

A Simple Stenting Method for Management of Hepatic Ductal Injury Secondary to Blunt Abdominal Trauma: Two Case Reports

We report two cases of liver injury with hepatic ductal disruption after blunt abdominal trauma. The first case involves a 23-year-old male. Because the bifurcation of the hepatic duct was longitudinally torn, two stenting catheters were inserted toward the right and left hepatic ducts without suture closure of the tear. The patient is well 10 years after the injury. The second case involves a 22-year-old male who suffered an infarction of the inferior portion of the medial segment of the left hepatic lobe as well as a laceration of the left hepatic duct, a 50% circumferential tear. A stenting catheter was introduced into the left hepatic duct, but the defect was not sutured. The patient is well 1.5 years after the injury. The catheter stenting method without suture repair or defect plasty is a simple and effective way to manage hepatic ductal injury.

Solitary malignant schwannoma of the duodenum with metastasis to the liver: Report of a case

Solitary malignant schwannoma of the duodenum is extremely rare. In fact, only two previous reports on successful radical resection of a solitary malignant schwannoma of the duodenum have been documented in the Japanese literature, and there are none in the English literature. We report herein the unique case of a 64-year-old man with a malignant schwannoma of the duodenum in whom both the primary lesion and a metachronous metastatic lesion were successfully resected. The patient initially underwent a Whipple procedure for a hypervascular tumor in the head of the pancreas. The tumor was composed of palisading spindle cells and scattered S-100 protein-positive cells with prominent mitotic figures, and was diagnosed as a malignant schwannoma of the duodenum. A second admission, 3 years later, revealed the presence of a solitary hypervascular hepatic tumor in the anterior segment of the right lobe of the liver. The hepatic tumor was resected and confirmed, microscopically and immunohistochemically, as a metastasis from the malignant schwannoma of the duodenum. The patient is alive 3 years and 6 months after his initial operation. To our knowledge no other report on the successful radical resection of both primary and metastatic lesions has been documented. This case report therefore highlights the importance of performing follow-up examinations focusing on the liver, and encourages an aggressive surgical attitude for the treatment of this unusual disease.

Vasculitis and pyrexia associated with superficial spreading gastric carcinoma.

A case of low grade fever developing about a month before the discovery of gastric carcinoma is reported. No findings of infection or collagen disease were revealed. The fever continued for about 3 months, but promptly disappeared after surgical removal of the tumor. A superficial spreading mucosal carcinoma with minimal invasion to the sub‐mucosa was seen in the antrum, showing the features of poorly differentiated adenocarcinoma. In addition, unique venous inflammation was recognized beneath and around the neoplasm. Arteries and lymph vessels did not exhibit any inflammatory changes. It was presumed that the gastric carcinoma had induced phlebitis, which subsequently brought about the fever. As to the pathogenetic mechanism, it was suggested that a substance produced by the carcinoma cells flowed into nearby veins to induce the phlebitis. Acta Pathol Jpn 42 : 293‐297, 1992.

Hepatic artery aneurysm

SummaryOne hundred and nineteen cases, including the one reported here, of hepatic artery aneurysm were reviewed. The clinical features and surgical management in four etiologic groups, consisting of arteriosclerosis, cholecystolithiasis, trauma and, specific diseases, were investigated. Interruption of the hepatic artery, entailing ligation of the hepatic artery, excision of the aneurysm without vascular reconstruction, and obliterative aneurysmorrhaphy, was done in 50 patients. Its high mortality rate (26%) was principally ascribed to delayed diagnosis or inappropriate site of interruption. If conditions such as shock, anoxia and portal thrombosis are avoided, interruption of the hepatic artery seems to be a safe and useful operative method for hepatic artery aneurysms, especially accompanied by severe local infection.

Vascular Changes in the Pancreaticoduodenal Allograft

* From the Second Department of Surgery, Tokyo University School of Medicine, 7-chome, Hongo, Bunkyo-ku, Tokyo, Japan. An allotransplanted organ is soon exposed to and attacked by the host’s immunologic reaction. Rapidly changing histologic features of the transplanted organ in the host environment have attracted an attention of many investigators. 1-4 Vascular changes in the transplanted organ are of vital importance in the graft rejection phenomenon because the graft vessel is the place where the host’s cytotoxic antibody5 first meets the graft antigen, and the host’s immature plasma cells make cytoplasmic continuity with the graft’s endothelial cells.’ Vascular changes in the allograft are of interest in comparison with polyarteritis nodosa,s lupus erythematodes and scleroderma which