Tetsuya Kanehiro

Adenosquamous carcinoma of the pancreas : preoperative diagnosis and molecular alterations

Adenosquamous carcinoma of the pancreas is a rare tumor which has a less favorable prognosis than common ductal cell carcinoma of the pancreas, and a definite preoperative diagnosis of this tumor is quite difficult. We herein report two cases of this rare variant. The patients were a 41-year-old man (patient 1) and a 67-year-old woman (patient 2). Patient 1 had a hypoechoic mass measuring 3 cm in the uncus of the pancreas, while patient 2 had a huge mass, measuring 8 cm, in the tail of the pancreas. Patient 2 was successfully diagnosed preoperatively as having an adenosquamous carcinoma, by cytological examination of the pure pancreatic juice obtained by endoscopic retrograde pancreatic juice aspiration. A pylorus-preserving pancreatoduodenectomy was performed for patient 1, and a distal pancreatectomy with resection of the spleen and the left kidney was performed for patient 2. Subsequent pathological findings of these two tumors revealed adenosquamous carcinoma of the pancreas. K-ras point mutation, p53 overexpression, and telomerase activity in both tumor specimens were detected by the mutant allele specific amplification method, immunohistochemical staining, and telomeric repeat amplification protocol assay, respectively. The two patients died of recurrent disease 5 and 4 months, respectively, after surgery. Cytological examination of pure pancreatic juice is a useful modality for the preoperative diagnosis of this tumor, and frequent molecular alterations may be associated with the poor prognosis of adenosquamous carcinoma of the pancreas.

Patient with perforation caused by emphysematous cholecystitis who showed flare on the skin of the right dorsal lumbar region and intraperitoneal free gas

We report an 84-year-old man with perforation caused by emphysematous cholecystitis who showed flare on the skin of the right dorsal lumbar region and intraperitoneal free gas. The patient was admitted for abdominal pain, abdominal swelling, and consciousness disorder 18 days after the onset. Abdominal computed tomography (CT) revealed emphysema in the gallbladder and a small amount of intraperitoneal free gas. Intraoperative findings suggested gangrenous cholecystitis. The gallbladder wall was perforated, and an abscess involving the right subphrenic region, the periphery of the liver and gallbladder, and the right paracolonic groove, was detected. The flare on the body surface may have reflected abscess formation in the right abdominal cavity. Emphysematous cholecystitis induces necrosis and perforation in many patients, and immediate strategies such as emergency surgery are important.

Successful pre-operative diagnosis of malignant intraductal papillary mucinous tumor of the pancreas by detecting telomerase activity.

SummaryBackground. Pre-operative differential diagnosis between and malignant intraductal papillary mucinous tumor (IPMT) of the pancreas is markedly difficult by imaging examination. In recent years, telomerase activity has been reported to be detected only in malignant tumors. Methods. A 52-yr-old man with abdominal pain was diagnosed with a IPMT through imaging examination. Telomerase activity of the pure pancreatic juice, which was obtained pre-operatively by endoscopic retrograde pancreatic juice aspiration (ERPJA), was analyzed by telomeric repeat amplification protocol (TRAP) assay. Results. Telomerase activity was detected in the pure pancreatic juice of the patient, who was diagnosed with a malignant IPMT. A pylorus-preserving pancreatoduodenectomy was performed, and subsequent pathological findings revealed the tumor to be adenocarcinoma in adenoma with papillary growth. Conclusion. Detection of telomerase activity of the pure pancreatic juice might be useful to distinguish benign from malignant IPMT pre-operatively.

Strictureplasty for short duodenal stenosis in Crohn's disease

Abstract: Involvement of the gastroduodenum is extremely rare in Crohns disease. For obstructing duodenal Crohns disease, bypass procedures have traditionally been selected. However, more recently, strictureplasty has become an acceptable surgical option. We treated two Crohns disease patients with short proximal duodenal stenosis, using Finney-type strictureplasty. Their postoperative courses were uneventful and they have remained asymptomatic during follow-up periods of more than 5 years, and 4 months, respectively. Owing to the good clinical results of our two patients, we consider strictureplasty to be indicated for short proximal duodenal stenosis in Crohns disease.

Clinical Characteristics and Surgical Treatment for Inguinal Endometriosis in Young Women of Reproductive Age

Aim: To study the characteristics and surgical treatment of inguinal endometriosis (IEM), which can occur in women of reproductive age. Methods: Patients who underwent groin surgery at the Hiroshima City Funairi Citizens Hospital between 2004 and 2017 were retrospectively examined. Patients with IEM were divided into 3 groups based on the site of occurrence as follows: at a hernia sac or hydrocele of Nuck’s canal (type I), round ligament (type II), or subcutaneous area (type III). Clinical characteristics were compared among groups. Results: Of 2,798 patients investigated, 28 were pathologically diagnosed as having IEM with 15, 10, and 3 classified as type I, II, and III respectively. All patients presented with a mass (median 20 mm) and/or bulge that mainly occurred at the right inguinal region. Sixteen patients presented with inguinal pain associated with menstruation. While the groups did not differ in terms of most clinical characteristics, the lack of a preoperative diagnosis of IEM occurred more frequently for type I than for types II and III. Conclusions: Because IEM-type I might be underdiagnosed preoperatively, complete resection of a hernia sac or hydrocele of Nuck’s canal with subsequent pathological examination is required for women of reproductive age with an inguinal disease.

A Case Report of Intramural Gallbladder Abscess after Two Years

壁内型胆嚢周囲膿瘍を形成して, 2年間の経過の後に切除した症例を経験したので報告する. 症例は92歳の男性で, 2000年11月, 右上腹部痛にて来院し, 急性胆嚢炎として保存的治療を受けて退院した. 2002年11月, 前回と同様の右上腹部痛を主訴に再来院し, 胆嚢炎増悪で入院となった. WBC 9,050/mm3, CRP 9.1mg嚢dlと炎症所見を認めた. 腹部超音波検査で胆嚢周囲への限局性の液体貯留および隔壁様構造を認めた. 腹部CTでは腫大した胆嚢様の構造とその内部に隔壁を認めた. 経皮的膿瘍ドレナージ後の造影では胆嚢と交通した膿瘍腔を認め, 無石性胆嚢炎からの胆嚢周囲膿瘍を形成したと診断した. 病理所見では壊疸性胆嚢炎および壁内型胆嚢周囲膿瘍と診断された. 本症例のように壁内型胆嚢周囲膿瘍の長期経過をみた報告例はまれであり, 消炎後の早期の切除が必要であると考えられた.

Impact of Cefazolin on the Gastrointestinal Microflora at the Gastrointestinal Surgery.

消化器手術後での抗菌剤の腸内細菌叢への影響を検討するため, 胃切除患者7例を対象に術後cefazolin投与 (3g/日, 4日間) し, 前後の糞便中の各種細菌数を算出した. 嫌気性菌総菌数は軽微だが有意 (p<0.05) な減少を示した (前: 10.3±0.34→後: 9.89±0.22 log CFU/g). 菌種別ではBacteroides spp., Eubacterium spp., Lactobacillus spp. (おのおのp<0.01), Veillonella (p<0.05) は有意の低下を, Bifidobacteriumspp. では低下傾向 (p=0.09) を認めた. 嫌気性菌の減少はcefazolinに対する感受性に関係なく同程度減少しており, cefazolinより絶食, 腸蠕動低下, ストレスなど手術の影響が関与したと考えた.好気性菌では菌数に変化なく, Enterococcus, Clostolidium, Pseudomonas aeruginosa, Candidaなどの耐性菌の増加は認めなかった. 以上よりcefazolin術後4日間の予防投与では, 腸内フローラの生態系はほぼ維持されたと推察した. したがって, cefazolinは消化器術後の予防抗菌剤として適切と考えた.