Nobuyuki Toyama

Segmental Small Bowel Transplantation in the Rat: Comparison of Lipid Absorption Between Jejunal and Ileal Grafts

BACKGROUND From the immunological point of view, it is very important to evaluate the efficacy of segmental small bowel transplantation and to determine which part of the intestine, jejunum, or ileum should be used. In the present study, we investigated the absorptive function of the transplanted jejunum and ileum in the rat. METHODS Syngeneic segmental small bowel transplantation (jejunal or ileal grafting) was performed. After surgery, body weight and fecal fat excretions were measured. In addition, bile acid concentration in bile juice was measured, and the response of both serum lipase and bile flow rate after oleic acid stimulation was evaluated. Recanalization of the lymphatic vessels was investigated by lymphangiography. RESULTS There was no significant difference in body weight change between normal controls, jejunum-transplanted rats, and ileum-transplanted rats. In short gut rats, however, body weight was significantly impaired. Fecal fat excretion in short gut rats was the highest in the four groups, and it was significantly lower in ileal grafts than in jejunal grafts. Ileum-transplanted rats also showed a significantly higher bile acid concentration in bile juice than jejunum-transplanted rats. After oleic acid stimulation, serum lipase responded better in ileal transplants than in jejunal transplants, but the bile flow rate did not show significant change in either group. Recanalization of the lymphatic vessels was established on the 28th postoperative day. CONCLUSIONS These results clearly show that ileal transplantation is more conducive to lipid absorption than jejunal transplantation.

Mucin-producing carcinoma of the gallbladder associated with primary sclerosing cholangitis and ulcerative colitis

Mucin-producing carcinoma of the gallbladder is very rare. We report here a case of mucin-producing carcinoma of the gallbladder associated with primary sclerosing cholangitis (PSC) and ulcerative colitis (UC). A 74-year-old female had been treated with salazosulfapyridine and ursodesoxycholic acid becase of UC and PSC. After 7 years of treatment, laboratory data showed that the liver function took a turn for the worse, and the patient was admitted to our hospital for further examination. Enhanced computed tomography and ultrasonography showed an enlarged gallbladder associated with wall thickening and diffuse papillary protrusion. Endoscopic retrograde cholangiography showed stenosis and dilatation of the bile duct, which were compatible with PSC. Under the diagnosis of an early carcinoma of the gallbladder, we performed simple cholecystectomy. The tumor showed a papillary growth pattern located diffusely in the gallbladder with a massive amount of mucin filling the gallbladder. Histologically, it was diagnosed as a papillary adenocarcinoma localized in the mucosal layer. To the best of our knowledge, this is the first case of mucin-producing carcinoma of the gallbladder associated with PSC and UC. PSC and UC patients should be regarded as a high-risk group not only for cholangiocarcinoma but also carcinoma of the gallbladder.

Pancreas head carcinoma with total fat replacement of the dorsal exocrine pancreas

We report a case of pancreas head carcinoma associated with fat replacement of the body and tail. A 68-year-old man presented with obstructive jaundice and was admitted to our hospital. Ultrasonography and computed tomography showed pancreas head tumor with a neighboring cystic lesion and fatty replacement of parenchyma of the pancreas body and tail. By endoscopic retrograde pancreatography, abruption of the main pancreatic duct and the presence of an accessory duct were detected. After percutaneous transhepatic biliary drainage, pancreatoduodenectomy was successfully performed. At laparotomy, the pancreas head was easily dissected from the replaced fatty tissue of the body and tail without continuity of the ductal system or parenchyma. Microscopic examination revealed the existence of an infiltrating ductal adenocarcinoma and a neighboring. cyst in the pancreas head. The dorsal exocrine pancreas was completely replaced by the fat tissues, in which viable Langerhans’ islets were scattered. The patient’s postoperative course was uneventful, and exogenous insulin administration was unnecessary for the maintenance of normal blood sugar level. Acquired fat replacement of the body and tail of the pancreas is an uncommon disorder, mimicking congenital agenesis of the dorsal pancreas. Though the mechanism is controversial, obstruction of the main pancreatic duct by a cystic lesion or carcinoma in the pancreas head is a possible cause of fatty degeneration of the pancreatic parenchyma.

Risk factors for intra-abdominal infection after pancreaticoduodenectomy - a retrospective analysis to evaluate the significance of preoperative biliary drainage and postoperative pancreatic fistula.

BACKGROUND/AIMS Intra-abdominal infection (IAI) after pancreaticoduodenectomy (PD) is a common cause of prolongation of postoperative hospital stay and readmission to the hospital following discharge. METHODOLOGY Two hundred and six patients undergoing PD were reviewed to investigate the risk factors for IAI after PD. Patients were separated into two groups: those who developed IAI after PD (Group A; n=44), and those who had not developed IAI after PD (Group B; n=162), the two groups were then compared to identify the risk factors for IAI after PD. A hundred and six patients (51.5%) underwent preoperative biliary drainage (PBD). RESULTS Multivariate analysis revealed that pancreatic fistula (PF) was an independent risk factor for IAI after PD (p<0.001; odds ratio=9.58; 95% confidence interval=4.37-21.0), but PBD was not a significant risk factor. CONCLUSIONS We demonstrated that the adequate PBD might not affect IAI after PD. On the other hand, PF was an independent risk factor for IAI after PD. A large randomized controlled trial, which would prove the effect of early removal of a prophylactic placed drain to prevent IAI, should be planned.

Acute pancreatitis secondary to duodenoduodenal intussusception in duodenal adenoma.

Duodenoduodenal intussusception is a rare condition that is in general caused by a tumor. We describe duodenoduodenal intussusception secondary to a tubulovillous adenoma that caused acute pancreatitis in a 31-year-old female. We resected a duodenal tumor from the submucosal layer and then simply closed the duodenal wall. To the best of our knowledge, this is the first description of acute pancreatitis secondary to duodenoduodenal intussusception by tubulovillous adenoma in the second part of the duodenum in an adult.

Fulminant second-set allograft rejection and endoscopic findings following small bowel transplantation in the rat

In the presensitized recipient who has been exposed to donor antigens, second-set rejection takes the form of severe hyperacute graft rejection. Secondset allograft rejection was studied following small bowel transplantation in the rat. Heterotopic intestinal grafting was performed from DA (RT1a) donors to PVG (RT1c) recipients 4 weeks after DA skin sensitization. The endoscopic images and histological specimens were compared with those of syngeneic and firstset rejected grafts. Endoscopically, diffuse erosions of the graft were detected from day 1. Mucosal necrosis progressed rapidly, and was accompanied by massive bleeding on days 3–5. These findings were similar to the course of severe necrotizing hemorrhagic enteritis. Histologically, interstitial edema and hemorrhage with massive infiltrations of neutrophils were manifested from day 1. Mesenteric vessels were completely occluded by thrombi on days 3–5. The grafted intestine had became totally necrotic by day 5. Microscopic findings strongly suggested that destructive graft necrosis was due to vascular damage caused by humoral factors. All the presensitized rats (n=11) died showing systemic septic signs by day 11 after small bowel transplantation. We concludes that lethal hyperacute rejection occurred in presensitized recipients, even when the graft was transplanted heterotopically. Endoscopic evaluation is beneficial for the early diagnosis of graft rejection. Immediate graft removal should be mandatory as a rescue treatment in second-set rejection of the small intestine.

Endoscopic findings in transplanted allo-intestine of rats after discontinuance of immunosuppressive agent

Abstract: In clinical practice, graft rejection in small-bowel transplantation should be diagnosed before irreversible condition of the graft. We have already reported the usefulness of endoscopic examination for the early detection of acute rejection in a rat model. Here we evaluated rejection after discontinuance of methyl-deoxyspergualin by endoscopy. Heterotopic small-bowel transplantation was performed by the cuff method from a DA to a LEW rat. Endoscopic and histological examinations were performed through the stomas. Two-week administration of methyldeoxyspergualin significantly prolonged graft survival. Graft rejection after discontinuance of the agent occurred much more slowly than rejection without the immunosuppressive drug. Erosive mucosal changes were endoscopically observed in the early phase of rejection in rats that did not receive the immunosuppressant. However, endoscopic findings after discontinuance of methyl-deoxyspergualin indicated edematous changes and thickening of the wall without erosion, and, histologically, the grafted intestine showed slowly-progressing rejection with flattened villi. If we pay attention to edematous changes and hardening of intestinal wall, and take selective biopsies, endoscopic examination may improve the early diagnosis of slowly progressive rejection in the clinical setting.

Risk factor for pancreatic fistula after pancreaticoduodenectomy performed by a surgeon during a learning curve: analysis of a single surgeon's experiences of 100 consecutive patients.

BACKGROUND/AIMS Among several kinds of morbidities, pancreatic fistula (PF) is the most common complication of pancreaticoduodenectomy (PD). However, it has not been clarified what kind of perioperative factors are risk factors of PF after PD is performed by a training surgeon. METHODOLOGY We evaluated the risk factors of PF after PD in which all procedures for 100 consecutive patients were performed by a single training surgeon, retrospectively. The 100 cases were divided into two groups and the first 50 cases were named Group A and the latter 50 cases were named Group B. RESULTS Multivariate analysis demonstrated that the absence of main pancreatic duct dilatation was an independent risk factor for grade B and grade C PF (p=0.0080; OR=5.311; 95% CI=1.116-7.025). There was no significant difference of the frequencies of grade B and grade C PF between Group A and Group B (p=0.13361). CONCLUSIONS We demonstrated that the absence of main pancreatic duct dilatation was an independent risk factor for grade B and grade C PF after PD was performed by a training surgeon; for those without pancreatic duct dilatation, PD can be performed by a surgeon in the earlier training period with an acceptable rate of PF.

Laparoscopic and percutaneous repair of a large midline incisional hernia extending to the bilateral subcostal region: A case report

Highlights • A hybrid laparoscopic and percutaneous repair for incisional hernia was described.• Percutaneous defect closure can be indicated for large hernia (>10 cm in diameter).• Mesh fixation should be limited below the costal margin in subcostal hernia.• Minimal organ injuries and obtaining more overlap are the advantages.• Postoperative pain is the disadvantage.