Masaru Mizuno

An analysis of mutagens in the contents of the biliary tract in pancreaticobiliary maljunction.

A reflux of pancreatic juice into the biliary tract due to pancreaticobiliary maljunction has been considered to be an important factor in the development of biliary tract carcinogenesis. It is known that the contents of the biliary tract contain not only activated pancreatic enzymes but also certain mutagens. The purpose of this study was thus to isolate and identify such mutagenic substances. A 1:1 mixture of the control bile and pancreatic juice was mixed with bovine enterokinase (10 mg/ml), and the mixture was incubated at 37°C for 12h. The mixture was demonstrated to be reproducibly mutagenic by the Ames test. The mutagenic substances in these mixtures, which were separated using organic analysis, were found to be included in the water-soluble fraction and to contain amino acids. Mutagenic substances are thought to have a molecular weight of 1500–3500 and to be a complex of low-molecular-weight, stable, mutagenic substances including amino acids and peptides.

The effect of arginine supplementation on growth hormone release and intestinal mucosal growth after massive small bowel resection in growing rats

Four-week-old male Sprague-Dawley rats underwent a 90% small bowel resection. From the fourth day after surgery, they were divided into group 1 and 2, and pair-fed by elemental diets (0.8 kcal/mL, 50 mL/day) with L-arginine (n = 10) or L-glycine (n = 11) as an isonitrogenous and isoenergetic supplement for 3 weeks. They were compared with each other 3 weeks after surgery. A statistical analysis was performed using the unpaired Students t test and the one-way factorial analysis of variance (ANOVA) using Bonferroni/Dunn multiple comparison test. A Pvalue of < .05 was considered significant. There were no significant differences between the two groups in food intake, body weight, tail length, residual ileal length, and plasma IGF-I level. However, the mean height of ileal villi in group 1 showed higher than that in group 2 (P < .01). Growth hormone-releasing hormone (GHRH) provocative tests (1 microg per rat, intravenously) showed the more significant elevation of growth hormone IGH) secretion in the arginine supplement group than that of glycine supplement group at 5 minutes (P < .05). There were no significant differences between basal levels of plasma rat GH in both groups. It is suggested that arginine has a possible significant role of GH secretion and intestinal mucosal growth after massive small bowel resection.

Single-port laparoscopic Heller myotomy and Dor fundoplication: initial experience with a new approach for the treatment of pediatric achalasia

PURPOSE The aim of this report was to evaluate the safety and feasibility of single-port laparoscopic Heller myotomy and Dor fundoplication (SPLHD) as treatment of pediatric esophageal achalasia. METHODS A 9-year-old boy with a significant history of achalasia underwent SPLHD. The single-port was inserted using an umbilical incision. The falciform ligament and left liver lobe were raised using an elevating suture, providing good visualization of the operative field at the cardia. The Heller myotomy was planned to be 4 cm long, extending 1 cm onto the gastric wall. RESULTS The SPLHD was successfully accomplished without the need for any skin incisions or additional ports. Oral intake was resumed on the first postoperative day, and the length of hospital stay was 8 days. The patient had complete resolution of dysphagia and regurgitation. No complications were noted, and the patient had an excellent cosmetic result. CONCLUSIONS The SPLHD is a safe and feasible procedure for symptomatic pediatric achalasia when performed by a surgeon experienced in laparoscopic and esophageal surgery.

Neonatal portal venous blood flowmetry by Doppler ultrasound for early diagnosis of ischemia in intestinal tract.

PURPOSE The aim of this article is to evaluate the utility of portal blood flow and other hemodynamic measurements for early diagnosis of ischemia that may cause necrotizing enterocolitis (NEC). PATIENTS AND METHODS We measured neonatal portal blood flow by Doppler ultrasound and performed hemodynamic examinations in 75 newborns without congenital anomalies. All newborns were followed for 1 month after birth. The average gestational period was 30.5 weeks, and the average birth weight was 1,172 g. RESULTS A positive correlation was observed between both body weight and the following parameters: portal vein cross-sectional area, blood flow velocity, and portal blood flow volume. A greater coefficient of correlation was observed between the portal vein cross-sectional area and weight in newborns weighing ≤ 1,500 g than in those weighing > 1,500 g. The portal vein cross-sectional area and blood flow velocity changed over time to maintain a fixed portal blood flow volume. The portal vein blood flow demonstrated a poor increase in patients with poor weight gain after birth. Seven infants demonstrated a reduction in portal vein blood flow before the development of abdominal symptoms. Both the cross-sectional area and blood flow velocity decreased over time before the onset of any symptoms of NEC. CONCLUSIONS A significant decline in portal blood flow volume may be useful for the early diagnosis of NEC.

Extremely short small bowel induces focal tubulointerstitial fibrosis.

Background Arginine becomes an essential amino acid after massive resection of the small bowel as a result of decreased biosynthesis of citrulline in the remaining small bowel. It is also reported that nitric oxide (NO) is synthesized from l -arginine by NO synthase (NOS), and NO is involved in the regulation of blood flow in the kidney. The authors observed a patient with an extremely short small bowel, showing focal tubulointerstitial fibrosis. The experiment was designed to clarify whether massive small bowel resection (SBR) produces focal tubulointerstitial fibrosis in the kidney. Methods An experimental study was performed using 4-week-old rats with 90% proximal SBR either with or without arginine supplementation for 6 weeks after surgery. Results In rats without arginine supplementation, low plasma levels of citrulline and arginine increased urinary excretion of orotate, and focal tubulointerstitial fibrosis was observed 6 weeks after 90% SBR. The data from plasma amino acid chromatography and increased excretion of urinary orotate suggested the presence of arginine deficiency. The kidney pathology was similar to that of our patient. Rats with arginine supplementation after 90% SBR and pair-fed control rats without 90% SBR showed almost normal glomeruli and tubulointerstitium. Conclusions Experimental study strongly suggests that arginine deficiency causes focal tubulointerstitial fibrosis in the kidney after massive SBR.

Effectiveness of neoadjuvant chemotherapy with cisplatin and irinotecan followed by surgery on small-cell carcinoma of the esophagus: A case report

Highlights • Small-cell carcinoma of the esophagus is a rare disease and a poor prognosis.• The optimum treatment strategy for SCCE remains to be established.• We report a case of advanced SCCE achieving a pathologically complete response with preoperative chemotherapy using CDDP and CPT-11, and long-term survival followed by surgery.• Neoadjuvant chemotherapy following esophagectomy could be a useful treatment option.

Pediatric Surgery: Pediatric Surgery

■ Explanation A diagnosis of hypertrophic pyloric stenosis is confirmed if ultrasonography shows a pyloric muscle ≥4 mm thick and a pyloric canal ≥16 mm long. Surgery is performed after definitive diagnosis except at institutions that perform conservative treatment with atropine as the first option. Pyloromyotomy is often performed as a semi-emergency treatment after improvement of dehydration and general condition with fluid replacement. Meanwhile, some institutions perform emergency surgery immediately after definitive diagnosis, because this surgical repair easily improves the patient’s condition. Patients resistant to atropine treatment and those undergoing prolonged treatment are also indicated for pyloromyotomy. Regarding the timing of surgery, 4 meta-analyses have compared laparoscopic pyloromyotomy and open pyloromyotomy (1–4) and report that laparoscopic surgery and laparotomy are completely equivalent with respect to the indications and timing for surgery, resulting in no significance between laparoscopic pyloromyotomy and open pyloromyotomy (4–9). In most cases of hypertrophic pyloric stenosis, laparoscopic surgery can be performed because of absence of bowel gas and good visibility under pneumoperitoneum. However, laparotomy is selected for patients with congenital heart disease complications who cannot undergo pneumoperitoneum as well as for emergency surgery at night when laparoscopic surgery cannot be performed.

Single-port laparoscopic adrenalectomy for a right-sided aldosterone-producing adenoma: a case report

IntroductionSingle-port laparoscopic adrenalectomy is one of the most interesting surgical advances. Here, we evaluate the safety and feasibility of single-port laparoscopic adrenalectomy as treatment for a right-sided aldosterone-producing adenoma.Case presentationA 39-year-old Japanese woman presented with hypertension and hypokalemia. Abdominal computed tomography and an endocrinological workup revealed a 19mm right adrenal tumor with primary aldosteronism. Our patient was informed of the details of the surgical procedure and our efforts to reduce the number of incisions needed - ideally, to a single incision - when removing her adrenal gland. A single-port laparoscopic adrenalectomy was attempted. A multichannel port was inserted through a 2.5cm umbilical incision. A 5mm flexible laparoscope, articulating laparoscopic dissector and tissue sealing device were the primary tools used in the operation. The right liver lobe was evaluated using a percutaneous instrument, providing good visualization of the operative field surrounding her right adrenal gland. The single-port laparoscopic adrenalectomy was successfully completed without any intraoperative complications. The operating time was 76 minutes, and her blood loss was 5mL. Oral intake was resumed on the first postoperative day, and the length of her hospital stay was three days. Her postoperative course was uneventful with no morbidity within one month of follow-up, and our patient had excellent cosmetic results.ConclusionsSingle-port laparoscopic adrenalectomy is a safe and feasible procedure for patients with a right-sided adrenal tumor when performed by a surgeon experienced in laparoscopic and adrenal surgery. However, more surgical experience using this technique is required to confirm our initial impressions.

Renal focal tubulointerstitial fibrosis with short bowel syndrome: report of a case.

Abstract.We report a male patient with short bowel syndrome (SBS) and renal focal tubulointerstitial fibrosis (FTIF). Seven years after surgery, he was introduced to us due to severe undernutrition, an impairment of growth hormone (GH) secretion, and abnormally low levels of plasma citrulline and arginine at 11 years 7 months of age, just before nutritional support using total parenteral nutrition (TPN) was begun. Thereafter, the support was changed to home TPN with GH supplementation. After an improvement of the disorders, GH was stopped at 17 years 3 months of age. However, hyperuricemia appeared and a renal biopsy revealed FTIF at 20 years of age. Home TPN was continued twice a week because the plasma arginine level was still low. His follow-up biopsy at 23 years of age showed morphometric amelioration. Arginine deficiency following SBS may be associated with FTIF. The cause of hyperuricemia after SBS therefore needs to be investigated in detail.

Stability of cervical esophagogastrostomy via hand-sewn anastomosis after esophagectomy for esophageal cancer

The aim of the present study is to evaluate the outcome of hand-sewn esophagogastric anastomosis during radical esophagectomy for esophageal cancer. The outcomes of 467 consecutive esophageal cancer patients who underwent cervical esophagogastric anastomosis using interrupted and double-layered sutures after radical esophagectomy via right thoracotomy or thoracoscopic surgery were retrospectively reviewed. Anastomotic leakage, including conduit necrosis, occurred in 11 of 467 patients (2.4%); 7 of 11 (63.6%) cases experienced only minor leakage, whereas the other four (36.4%) patients had major leakage that required surgical or radiologic intervention, including two patients of conduit necrosis. Anastomotic leakages were more frequently observed after retrosternal reconstruction compared with the posterior mediastinal route (P < 0.0001). The median time to healing of leakage was 40 days (range: 14-97 days). Two patients (2/467, 0.4%) died in the hospital due to sepsis caused by the leakage and conduit necrosis. Twelve patients (2.6%) developed anastomotic stenosis, which was improved by dilatation in all patients. Hand-sewn cervical esophagogastric anastomosis is a stable and highly safe method of radical esophagectomy for esophageal cancer.