Mitsugi Shimoda

Performance of Integrated FDG-PET/Contrast-enhanced CT in the Diagnosis of Recurrent Pancreatic Cancer: Comparison with Integrated FDG-PET/Non-contrast-enhanced CT and Enhanced CT

PurposeThe purpose of this study is to evaluate the accuracy of 2-deoxy-2-[F-18]fluoro-D-glucose-positron emission tomography (FDG-PET)/computed tomography (CT) with intravenous contrast for depiction of recurrent pancreatic cancer, compared with PET/non-enhanced CT and CT.ProcedureForty-five patients previously treated for pancreatic cancer underwent PET/CT for suspected recurrence. Lesion status was determined on the basis of histopathology and radiological imaging follow-up.ResultsPatient-based analysis showed that sensitivity, specificity, and accuracy of PET/contrast-enhanced CT were 91.7%, 95.2%, and 93.3%, respectively, whereas those of PET/non-enhanced CT were 83.3%, 90.5%, and 86.7%, respectively, and those of enhanced CT were 66.7%, 85.7%, and 75.6%, respectively. In 21 patients whom the final diagnosis was obtained from the histopathologic examination, those figures of PET/contrast-enhanced CT were 94.7%, 50.0%, and 90.4%, respectively. The sensitivity of PET/contrast-enhanced CT in detecting local recurrence, abdominal lymph node metastasis, and peritoneal dissemination were 83.3%, 87.5%, and 83.3%, respectively.ConclusionPET/contrast-enhanced CT is an accurate modality for assessing recurrence of pancreatic cancer.

Protective effect of ischemic preconditioning against liver injury after major hepatectomy using the intermittent pringle maneuver in swine.

Objective: To investigate whether ischemic preconditioning (IP) protects the liver against ischemia-reperfusion injury (I/R-I) after major hepatectomy through intermittent hepatic pedicle clamping (IC) in a swine liver resection model. Background: Although many studies have reported a protective effect of IP against continuous hepatic ischemia, it has not been elucidated whether IP protects the liver against I/R-I after hepatectomy using IC. This is the first study to evaluate the effect of IP in a swine major hepatectomy model using IC. Methods: Pigs (n = 12) were divided into 2 groups (IP or non-IP). In the IP group, livers were subjected to IP (10 min ischemia and 10 min reperfusion) before liver resection using IC (15 min ischemia and 5 min reperfusion). A left hemihepatectomy was then performed using IC in both groups. Hemodynamic changes and plasma concentrations of aspartate aminotransferase, lactate dehydrogenase, lactic acid and hyaluronic acid were measured at 60, 120 and 180 min after hepatectomy. Apoptosis (TUNEL staining and electron microscopy), plasma tumor necrosis factor-α (TNF-α) and NO2–/NO3– were evaluated for 180 min after hepatectomy. Results: There were no significant differences in body weight, blood loss, resected liver weight, Pringle time or hemodynamic changes between the 2 groups. IP significantly reduced plasma aspartate aminotransferase levels for 180 min after hepatectomy (IP: 135.8 ± 13.5 vs. non-IP: 199 ± 16.8 IU/l; p = 0.018). In the non-IP group, apoptotic changes in sinusoidal endothelial cells were observed with increased plasma TNF-α levels. IP protected liver injury from increase in plasma TNF-α (p = 0.042). Significantly fewer apoptotic cells were seen in the IP than in the non-IP group (p = 0.002). Plasma levels of lactate dehydrogenase, lactic acid and NO2–/NO3– in the IP group tended to be lower than those in the non-IP group. Conclusions: IP prior to hepatectomy with IC resulted in less hepatic injury and apoptotic cell death than in livers not subjected to IP. IP with IC has the potential to improve the clinical postoperative course of patients undergoing hepatectomy.

Intra-abdominal hemorrhage due to rupture of a splenic vein aneurysm: A case report

Splenic vein aneurysm (SVA) is extremely rare. Most patients with an SVA have portal hypertension. In this report we describe the first recorded case of intra-abdominal hemorrhage due to rupture of an SVA in a patient without evidence of portal hypertension. A 72-year-old man was admitted to our medical center in a state of shock, with complaints of acute abdominal pain and abdominal distention. Preoperatively, abdominal ultrasonography demonstrated an echo-free space in the abdomen, suggesting the presence of a fluid collection. In addition, computed tomography revealed an enhanced lesion with contrast material in the pancreatic tail. An emergency operation showed bleeding from the SVA near the pancreatic tail. Consequently, a distal pancreatectomy with splenectomy was performed. Histologically the lesion was diagnosed as an SVA surrounded by pancreatic tissue with chronic inflammatory changes. The patient’s postoperative course was uneventful.

Biliary Papillomatosis Arising in a Congenital Choledochal Cyst: Report of a Case

Abstract.We report a rare case of biliary papillomatosis arising in a congenital choledochal cyst, with an anomalous junction of the pancreatobiliary ductal system (AJPBDS). A 50-year-old woman was admitted to our department with epigastralgia, and imaging studies showed two masses in the cystic common bile duct and an AJPBDS. We made a preoperative diagnosis of biliary tract cancer, considering the size of the masses and the presence of the AJPBDS, and performed a pylorus-preserving pancreatoduodenectomy. The resected specimen contained two papillary tumors, which were subsequently diagnosed as benign papillomas. Histopathological and oncological examinations indicated that the lesions were involved in the development and progression of carcinogenesis because a point mutation of the K-ras gene and overexpression of p53 protein were detected. These findings suggest that biliary papillomatosis is a precancerous lesion induced by an AJPBDS.

Hepatectomy in patients with nonuremic minimal renal failure

In this study, the perioperative management and short-term outcome of hepatectomy were evaluated in patients with nonuremic minimal renal failure to assess the safety of hepatectomy in such patients. Ninety-one patients who underwent hepatectomy were retrospectively divided into two groups based on their creatinine clearance (Ccr) values: a group with Ccr values ⩾50 but <100 ml/min (group 1; n=77) and a group with Ccr values of ⩾20 to <50 ml/min (group 2; n=14). Preoperative patient characteristics, intraoperative parameters (including operation time and blood loss), and postoperative management and complications were evaluated. The preoperative evaluation showed no differences in liver function between the two groups, and there were no statistically significant differences between the two groups in intraoperative blood loss (522 ml in group 1 and 806 ml in group 2) or intraoperative urine volume (1.01 ml/kg per hour in group 1 and 0.75 ml/kg per hour in group 2). The difference between the two groups in postoperative complications was not statistically significant. None of the patients in group 2 required dialysis therapy, and no patients died as a result of hepatectomy or hepatectomy-related causes. Adequate indications, appropriate operative procedures, and perioperative management can enable hepatectomy to be performed safely in patients with nonuremic minimal renal failure.

Ball-valve gastric tumor associated with anomalous junction of the pancreatico-biliary ductal system and a right-sided round ligament: Report of a case

We report the case of a ball-valve gastric tumor associated with anomalous junction of the pancreatico-biliary ductal system (AJPBDS) and a right-sided round ligament, misdiagnosed preoperatively as advanced gastric cancer with pancreatic head invasion. A 72-year-old woman presented with chest pain, but laboratory data showed only anemia. Gastroscopy revealed a bleeding polypoid gastric tumor in the anterior wall of the stomach, herniating into the duodenum (ball-valve syndrome), and a Bormann type-2 tumor in the posterior wall. Ultrasonography showed gallbladder stones, dilatation of the intrahepatic bile duct and pancreatic duct, and a left-sided gallbladder (attributed to a right-sided round ligament with anomalous branches of the portal veins). Laparotomy revealed that the gastric tumors were not advanced cancer invading the pancreatic head. Intraoperative cholangiography showed an AJPBDS, causing dilatation of the intrahepatic bile duct and pancreatic duct. We performed distal gastrectomy and cholecystectomy without biliary diversion. Microscopy revealed that the polypoid tumor was a hyperplastic polyp.

Middle bile duct cancer with portal vein tumor thrombus

BackgroundTumor thrombus in the portal vein is a common complication of hepatocellular carcinoma, but an extremely rare complication of common bile duct cancer.Case presentationA 78-year-old woman was referred to our department because of jaundice. Laboratory data showed severe liver dysfunction with high serum levels of total bilirubin and CA19-9. Computed tomography showed lesions in the middle bile duct and main portal vein. FDG PET scan and 3D imaging showed hot spots in the same location as those revealed by CT. Under a diagnosis of middle bile duct cancer with portal vein tumor thrombus, the patient underwent surgery. At laparotomy, the main tumor was found to be located in the middle bile duct with a tumor thrombus, 2 cm in diameter, in the main portal vein. The patient underwent pancreatoduodenectomy with thrombectomy. Histological examination showed that this thrombus had the same histological features as those of the main bile duct cancer (poorly differentiated adenocarcinoma). The postoperative course was uneventful and the patient is doing well without any signs of recurrence 18 months after surgery.ConclusionTo our knowledge, this is the first report of successful resection of middle bile duct cancer with portal vein tumor thrombus.

The use of double-straight needle device in laparoscopic incisional and ventral hernia repair.

Incisional and ventral hernias are good indications for laparoscopic hernia repair. A successful repair requires complete covering of the hernia defect, adequate tension of the prosthesis, and secure stapling by a hernia stapler. The authors introduce their technique using a double-straight needle device. This technique is easy and quick and achieves adequate fixation between the prosthesis and the abdominal wall, which reduces operating time and provides cosmetic benefit.