Yasuyuki Kawachi

Liver perfusion chemotherapy with 5-Fluorouracil followed by systemic gemcitabine administration for resected pancreatic cancer: preliminary results of a prospective phase 2 study.

Objectives: Liver perfusion chemotherapy (LPC) for pancreatic cancer has been rarely undertaken in a postoperative adjuvant setting. We evaluated the feasibility and antitumor efficacy of LPC with 5-fluorouracil (5-FU) followed by gemcitabine treatment. Methods: This prospective study enrolled 27 patients who underwent pancreatic resection and subsequent LPC + gemcitabine treatment during a 3-year period. The liver was infused with 5-FU (125 mg/body per day per route) via both routes of hepatic artery and portal vein for more than 21 days. After that, gemcitabine (1000 mg/m2) was administered biweekly. Results: Portal vein thrombosis developed in 1 patient, but 89% patients tolerated LPC for more than 21 days with no life-threatening complication. Systemic administration of gemcitabine was accomplished in 93%; however, 1 patient died of serious capillary leak syndrome. No grade 4 toxicity was recorded, except for that patient. Median survival time and disease-free survival were 27.5 and 24.5 months, respectively. Hepatic relapse was observed in 25.9% (n = 7). Survival was in favor of paraaortic node-negative cases (n = 20) with a 2-year survival of 68.7%. Conclusions: Liver perfusion chemotherapy was feasible with acceptable toxicity. Systemic use of gemcitabine also seems to be safe for the most part. This adjuvant chemotherapy shows promising survival benefit and seems to be indicative to paraaortic node-negative tumors.

Localized small-bowel infarction caused by Aspergillus during chemotherapy for acute myeloid leukemia: Report of a case

Aspergillosis is a common fungal infection in immunocompromised patients undergoing chemotherapy. The incidence of invasive fungal infection in these patients has increased dramatically in recent years. We report a case of small-bowel infarction caused by Aspergillus in a 48-year-old man who was receiving chemotherapy for acute myeloid leukemia. On day 20 after the start of chemotherapy, right lower abdominal pain and rebound tenderness developed, with a high fever. A contrast-enhanced computed tomography scan showed a semicircular perfusion defect in the ileum. Thus, we performed partial resection of the ileum with primary anastomosis. Macroscopically, the ileum had mucosal ulcerations. Microscopically, there was transmural necrosis with microperforation and Aspergillus invading necrotic tissue and blood vessels. The patient had an uneventful postoperative course and was discharged 14 days after the procedure. Intestinal aspergillosis is rare and associated with high mortality. Thus, it should be considered in the differential diagnosis of neutropenic patients with sudden abdominal pain and fever.

A Case of Spontaneous Ruptured Solid Pseudopapillary Tumor of Pancreas Resected by Laparoscopic Surgery

Solid pseudopapillary tumor (SPT) is an uncommon neoplasm of the pancreas. A rare case of spontaneous rupture of SPT is reported. A 13-year-old female felt acute abdominal pain without blunt abdominal trauma. Enhanced computed tomography (CT) revealed a tumor in the pancreas tail with fluid collection around it. The tumor was diagnosed as SPT with hemoperitoneum associated with spontaneous rupture. The bleeding was stopped conservatively and she was referred for surgery at three months after the rupture. At that time, CT revealed a tumor 4 cm in diameter, which protruded from pancreas tail without distant metastases. Since peritoneal dissemination was not seen on intraoperative exploration, laparoscopic enucleation was performed. Pathologically, the tumor was diagnosed as SPT with rupture of the capsule of tumor, and complete resection was confirmed. The patient has been followed up for two years, and she is alive without recurrence.

Rupture of a Pancreaticoduodenal Artery Aneurysm into the Common Bile Duct Resulting in Fatal Suppurative Cholangitis: Report of a Case

A 73-year-old man with a preoperative diagnosis of cholangitis underwent a laparotomy, which revealed a necrotized gallbladder and dilated common bile duct, both filled with foul-smelling clotted blood. We could not find the cause of hemobilia at this time. On postoperative day (POD) 11, an exsanguinating hemorrhage suddenly began pouring from the T-tube, suggesting the possibility of a ruptured gastroduodenal artery branch aneurysm into the biliary system. Immediate angiography confirmed multiple aneurysms of the gastroduodenal artery. Embolization was done and there was no further bleeding from the T-tube; however, the patient’s condition was too critical for recovery and he died on POD 17. At autopsy, we found multiple aneurysms in the gastroduodenal artery. The posterior superior pancreaticoduodenal artery, diverging from one of the aneurysms of the gastroduodenal artery, formed another tiny aneurysm subjacent to the common bile duct wall. Rupture of this aneurysm into the biliary system caused fatal acute obstructive suppurative cholangitis.

Reduction en masse can be treated using pure laparoscopic transabdominal preperitoneal hernioplasty following early CT diagnosis: report of a case.

Reduction en masse refers to the rare occurrence of an incarcerated inguinal hernia arising from the manual reduction of a hernia. Such a condition constitutes a medical emergency because the hernia contents, such as the small bowel, remain strangulated in the preperitoneal space. Therefore, an early and accurate diagnosis, with early treatment, is important. A 61-year-old Japanese man presented with an irreducible lump over his left groin, leading to the reduction of an incarcerated inguinal hernia by a doctor at another hospital. Later, he was admitted to our hospital with vomiting and abdominal pain. Computed tomography showed a ball-like lesion containing an incarcerated bowel loop over his left pelvis. The patient was diagnosed with an incarcerated small bowel obstruction due to a reduction en masse; a laparoscopic transabdominal preperitoneal (TAPP) hernioplasty was performed. TAPP hernioplasty is a safe method for treating reductions en masse that allows confirmation of bowel viability.

A case of multiple esophageal carcinomas concomitant with achalasia

A 51-year-old man had been diagnosed with esophageal achalasia 26 years previously; however, regular medical examination was not performed. He presented to the hospital for severe back pain and increased dysphagia during the past 7 months. Endoscopic examination showed the presence of multiple primary carcinoma of the esophagus with achalasia. An esophagogram showed sigmoid-type achalasia with grade III dilatation. Subtotal esophagectomy with mediastinal and abdominal lymphadenectomy was performed. Histopathological examination showed three squamous cell carcinomas at pStage IVB, including pT3 and pM1b. Furthermore, all the three lesions located in the large, slightly iodine-stained area showed hyperplasia with inflammatory cells. Although adjuvant chemotherapy was administered, the patient died of recurrence on the right chest wall and in the stomach, liver, and left iliac bone at 23 months after operation. A patient with esophageal achalasia should be carefully followed up by endoscopy with iodine staining.

Clinical trials of long-term RF local hyperthermia for advanced gastric cancer

The effect of local hyperthermotherapy (HT) using 13.56-MHz radiofrequency (RF) capacitive heating was evaluated in 25 patients with unresectable or recurrent gastric cancer. HT was carried out once to 3 times a week for a duration of one hour at each session. Patients who underwent RF-HT frequently showed maintenance of performance status, symptomatic improvement and a reduction in tumor size. Moreover, the survival time of 9 patients who had numerous metastases to the distant perioneum was significantly high (p<0.01), compared with 42 historical control patients who also had massive peritoneal dissemination, but had not received HT. The results of this study therefore indicate RF-HT to be a favorable modality in the palliative treatment of patients with far-advanced gastric cancer.

Splenic Involvement in Hereditary Hemorrhagic Telangiectasia

A 33-year-old man who presented with prolonged epigastric pain was referred to our hospital. He had experienced recurrent epistaxis and had a family history of hereditary hemorrhagic telangiectasia. Computed tomography and magnetic resonance imaging revealed splenomegaly and a 9 cm hypervascular mass in his spleen. Computed tomography also showed a pulmonary arteriovenous malformation and heterogeneous enhancement of the liver parenchyma, suggesting the presence of arteriosystemic shunts and telangiectases. Based on these findings, the patient was definitely diagnosed with hereditary hemorrhagic telangiectasia according to Curaçao criteria. He underwent splenectomy, and his symptoms disappeared after surgery. Pathological examination of the resected specimen revealed that the hypervascular lesion of the spleen was not a tumor but was composed of abnormal vessels associated with hereditary hemorrhagic telangiectasia. Symptomatic splenic involvement may be a rare manifestation of hereditary hemorrhagic telangiectasia but can be revealed by imaging modalities.

Report of 3 Cases of Pregnancy and Delivery after lleo-anal Anastomosis due to Familial Adenomatous Polyposis.

女性においては回腸肛門吻合術後の生活の質を評価する重要な要素として, 妊娠, 出産を挙げることができる.家族性大腸腺腫症に対して行われた回腸肛門吻合術後の出産例3例を経験したので報告し, 妊娠中の排便状況の変化および合併症につき検討した.3例とも術後の肛門管最大静止圧は70cmH2O以上 (正常100cmH2O) であった.いずれも帝王切開による出産で, 子に異常を認めなかった.帝王切開の適応は, それぞれ症例1は胎児の横位, 症例2は頻回腹部手術, および症例3は妊娠後期のイレウスによる腸切除術であった.妊娠前の排便回数は1日6～8回であり, 失禁はなかった.妊娠中, および出産前後において排便状況が悪化することはなかった.回腸肛門吻合術後の出産は十分可能で, 子にも問題ないことが示された.妊娠は回腸肛門吻合術後の排便機能に悪影響は及ぼさないと結論された.ただし妊娠中イレウスの発生に注意すべきである.

Effect of Intra-Arterial Injection of Mitoxantrone-Lipiodol Emulsion on Hepatocellular Carcinoma

The effect of intra-arterial injection of mitoxantrone emulsified with ethiodized oil was investigated in 24 patients with hepatocellular carcinoma. After treatment, 6 of the patients underwent hepatectomy. In 18 unresected cases, there were 8 (44%) partial responses, which had continued 2 to 10 months (mean, 7.4 months). In the remaining 6 resected cases, the necrotic areas in the main nodules accounted for 65% (mean, 85%) of the nodule, with complete necrosis in three cases. The results in this preliminary study are encouraging to further study.