Shigehiro Shiozaki

Milk-based test as a preventive method for chylous ascites following pancreatic resection.

Background/Purpose: The incidence and natural history of postoperative chylous ascites are not well understood. This complication causes malnutrition and prolonged hospital stay. We investigated our institution’s experience involving chylous ascites, especially following pancreatectomy. Additionally, we designed a new intraoperative method dubbed the ‘milk test’ for preventing chylous ascites. Methods: Five cases of chylous ascites following pancreatectomy from April 2001 through March 2004 were studied retrospectively. The milk test was carried out prospectively. Such rates as positivity and incidence of ascites were examined. Results: Of 65 cases (40 pancreatoduodenectomy; 25 distal pancreatectomy), 5 (7.7%) developed chylous ascites following pancreatic resection. All cases underwent octreotide and total parenteral nutrition treatment. From April 2004 through March 2009, the milk test was used in 104 cases. Surgical procedures comprised pancreatoduodenectomy (n = 78) and distal pancreatectomy (n = 23). Of these cases, 23 (22.1%) tested positive. No significant difference in positive rates was observed between the procedures and diseases. After initiation of the milk test, chylous ascites incidence decreased from 7.7 to 2.9%. Conclusions: For chylous ascites, octreotide and total parenteral nutrition treatments are useful. However, the milk test was found to be a safe and effective method for prevention of chylous ascites following pancreatectomy.

Augmentation of antitumor effect on syngeneic murine solid tumors by an interleukin 2 slow delivery system, the IL-2 mini-pellet

We evaluated the antitumor effect of an interleukin 2 (IL-2) slow delivery system, the IL-2 mini-pellet, in two murine solid tumor models, and also investigated the enhancement of its therapeutic effect by serial administration. The IL-2 mini-pellet contains 1 × 106 units of IL-2 and releases it slowlyin vivo. In our experiment, the IL-2 mini-pellet was administered subcutaneously near the tumor site in combination with the intravenous injection of lymphokine-activated killer (LAK) cells. When this regimen was given on days 8 and 11 after the subcutaneous inoculation of Meth A fibrosarcoma into BALB/c mice, tumor growth was significantly inhibited (p < 0.05) compared to tumor growth in untreated controls. Moreover, the IL-2 mini-pellet alone was also effective in inhibiting tumor growth. In another experiment, MH134 hepatoma was inoculated into C3H/He mice. Both administration of the IL-2 minipellet alone and in combination with LAK cells resulted in complete tumor regression in four of five mice. In a third experiment, serial administration of the IL-2 mini-pellet at 3- or 5-day intervals prolonged the suppression of Meth A fibrosarcoma growth in BALB/c mice. These results suggested that the IL-2 mini-pellet could be applied to cancer immunotherapy and that its antitumor effect could be prolonged by serial administration.

Sclerosing angiomatoid nodular transformation of the spleen presenting rapid growth after adrenalectomy: Report of a case

Highlights • SANT displayed a rapid growth in size from 20 mm to 70 mm during 3 years after adrenalectomy.• Splenectomy was performed by hand assisted laparoscopic surgery (HALS).• Corticosteroids might be useful for treating SANT.

Repeated resections for liver metastasis from primary adrenocortical carcinoma: A case report

Highlights • Adrenal cortical carcinoma (ACC) is rare, often recurring, and has a poor prognosis.• Surgery remains the optimal treatment for ACC, due to chemotherapy’s ineffectiveness.• Our patient developed 2 liver metastases after right adrenalectomy (1.5 and 4 years).• Therefore, complete surgical resection should be considered in similar cases.

Survival of patients treated by an autonomic nerve-preserving gastrectomy for early gastric cancer

PurposeAutonomic nerve preservation in a gastrectomy for gastric cancer improves the postoperative quality of life. We retrospectively examined the survival of patients treated by an autonomic nerve-preserving gastrectomy in comparison to the survival of the patients treated by a conventional gastrectomy.MethodsThe survival of 385 patients treated by an autonomic nerve-preserving gastrectomy for clinical early gastric cancer (the ANP group) was compared with that of 285 patients treated by a conventional gastrectomy (non-ANP group).ResultsAmong the ANP group, the numbers of patients with tumor invasion to the mucosa, submucosa, and muscularis propria were 210, 166, and 9, respectively, whereas the numbers of patients with lymph node metastasis grades of N0, N1, and N2 were 360, 21, and 4, respectively. The overall 5-year survival rate of the ANP group was 94.7%, which was superior to that of the non-ANP group (90.4%; P = 0.003). The 5-year survival rates of patients with lymph node metastasis were 94.9% and 91.8% in the ANP and non-ANP groups, respectively (P = 0.733). Only 3 patients in the ANP group died from gastric cancer.ConclusionsThe survival of patients treated by an autonomic nerve-preserving gastrectomy was equivalent to that of patients treated by a conventional gastrectomy, thus suggesting that an autonomic nervepreserving gastrectomy could be a useful procedure for the treatment of early gastric cancer.

Changes over time in milk test results following pancreatectomy

AIM To investigate changes over time in, and effects of sealing technology on, milk test results following pancreatectomy. METHODS From April 2008 to October 2013, 66 pancreatic resections were performed at the Iwakuni Clinical Center. The milk test has been routinely conducted at the institute whenever possible during pancreatectomy. The milk test comprises the following procedure: A nasogastric tube is inserted until the third portion of the duodenum, followed by injection of 100 mL of milk through the tube. If a chyle leak is present, the patient tests positive in this milk test based on the observation of a white milky discharge. Positive milk test rates, leakage sites, and chylous ascites incidence were examined. LigaSure™ (LS; Covidien, Dublin, Ireland), a vessel-sealing device, is routinely used in pancreatectomy. Positive milk test rates before and after use of LS, as well as drain discharge volume at the 2(nd) and 3(rd) postoperative days, were compared retrospectively. Finally, positive milk test rates and chylous ascites incidence were compared with the results of a previous report. RESULTS Fifty-nine milk tests were conducted during pancreatectomy. The positive milk test rate for all pancreatectomy cases was 13.6% (8 of 59 cases). One case developed postoperative chylous ascites (2.1% among the pancreatoduedenectomy cases and 1.7% among all pancreatectomies). Positive rates by procedure were 12.8% for pancreatoduodenectomy and 22.2% for distal pancreatectomy. Positive rates by disease were 17.9% for pancreatic and 5.9% for biliary diseases. When comparing results from before and after use of LS, positive milk test rates in pancreatoduodenectomy were 13.0% before and 12.5% after, while those in distal pancreatectomy were 33.3% and 0%. Drainage volume tended to decrease when LS was used on the 3(rd) postoperative day (volumes were 424 ± 303 mL before LS and 285 ± 185 mL after, P = 0.056). Both chylous ascites incidence and positive milk test rates decreased slightly compared with those rates from the previous study. CONCLUSION Positive milk test rates and chylous ascites incidence decreased over time. Sealing technology may thus play an important role in preventing postoperative chylous ascites.

CLINICOPATHOLOGICAL ANALYSIS OF GASTRIC MUCOSAL CANCER INVADING LYMPH VESSELS OR THE VEINS OF THE STOMACH WALL

In total, 573 lesions were resected from 518 patients with primary gastric mucosal cancer in Hiroshima City Hospital over the last 20 years, and the patients with ly(+) or v(+) lesions were analyzed from the clinicopathological point of view. The results were as follows. 1) 17 patients (3.0%) had ly(+) lesions, 3 (0.6%) had v(+) lesions. 2) In all but one case the lesions were located in the M or A area. 3) In all cases except two the lesions were depressed or mixed type. 4) Although one lesion was pap, the others were sig or tub 1, 2. However, there were no significant differences between the differentiated and undifferentiated types. 5) The maximal tumor diameter ranged from 1.5cm in the n(+) cases, but in the ly(+) cases from 0.7cm less than those cases. 6) 12 patients had n(+). Although 7 of the latter had ly(+), there were 3 n(+) cases even among the ly(-) cases. Furthermore, the 10 cases had depressive compartment. 7) Two patients died of another disease and one died of bone metastasis. The other patients are all alive. These results indicate that gastrectomy with node dissection should be done for the depressed or mixed type of lesion which has the possibility of being not only n(+) but also ly(+), v(+) even in the case of mucosal cancer.

Bone metabolism on long-term follow-up after total parathyroidectomy with autotransplantation.

二次性副甲状腺機能亢進症による腎性骨異栄養症 (ROD) に対して上皮小体全摘一部自家移植術 (PTX-AT) が行われているが, 術後3年以上の遠隔期における骨代謝, 骨所見に関する報告は少ない. 過去8年で38例に, PTX-ATを施行した. このうち術後3年以上経過した27症例について骨代謝の生化学的指標と, 全身骨X線所見について検討した. 透析歴は120-235か月 (平均181.1±30.7か月), PTX-AT後36-89か月 (平均61.9±11.9か月) を経過していた. C-PTHは術直後より減少し, 術後3年で5ng/ml以下のものは22例で, 残り5例中4例は術後もほとんど減少せず, その後の検査で残存副甲状腺を確認した. 骨新生の指標となるオステオカルシンを, 術後症例 (PTX-AT群) とC-PTH 10ng/ml以上の二次性副甲状腺機能亢進症例 (2°HPT群) で比較検討すると, PTX-AT群 (n=26) は平均106.9±98.7ng/ml, 2°HPT群 (n=27) は平均230.9±157.9ng/mlで, 有意にPTX-AT群が低値を示した (p<0.005). また, PTX-AT群では100ng/ml以下のものは19例でその全例がC-PTH 5ng/ml以下であった. 100ng/ml以上の8例は, 2°HPT群と有意差を認めなかった. さらに, 両群においてオステオカルシンとC-PTHは正の相関が認められた (p=0.05). 全身骨X線所見を1. 手指骨 (Tuft resorption, TR), 2. 頭蓋骨 (Salt and pepper, SP), 3. 腰椎 (Rugger jersey, RJ) の骨吸収像に分けてPTX-AT前後で比較検討した.1) TR (n=23): 悪化例0, 不変例2, 改善例21, 2) SP (n=21): 悪化例0, 不変例1, 改善例20, 3) RJ (n=21): 悪化例1, 不変例10, 改善例10.以上より, PTX-ATにより手指骨, 頭蓋骨は著明に改善するが, 腰椎は半数が不変であり改善傾向が少なかった. また, 術後持続副甲状腺機能亢進症を呈する症例では, 骨所見改善に乏しく, 骨代謝の生化学的指標のC-PTH, オステオカルシンと骨所見は相関するものと考えられた.

Clinical application of cascade filtration combined with glassbead adsorbents in cancer patients

Cascade filtration (CF) was applied to patients with advanced cancers. To selectively remove immunosuppressive factors with molecular weight lower than albumin, adsbor-bents combined with CF were examined. Among 11 kinds of adsorbents, glassbead adsorbents with pore size 100A were the most effective in adsorbing such substances. Clinically, a column packed with glassbead adsorbents was concomitantly used with CF. The second filtrate was passed through the column and returned to the patient. The removal rate of immunosuppressive substances with molecular weight lower than albumin was only 20% by CF alone, but more than 50% by CF combined with glassbead adsorbents. Clinical symptoms such as severe back pain and general malaise were drastically improved during and after therapy. These results suggest that CF combined with glassbead adsorbents is an effective adjunctive modality to cancer therapy.