Yukihiko Karasawa

Hepatic Resection for Metastatic Tumors From Gastric Cancer

ObjectiveTo assess the surgical results and clinicopathologic features of hepatic metastases from gastric adenocarcinoma to identify patients with a better probability of survival. Summary Background DataMany studies have reported the benefit of hepatic resection for metastatic tumors from colorectal cancer. However, indications for a surgical approach for gastric adenocarcinoma involving the liver have not been clearly defined. MethodsNinety (11%) of 807 patients with primary gastric cancer were diagnosed with synchronous (n = 78) or metachronous (n = 12) hepatic metastases. Of these, 19 underwent 20 resections intended to cure the metastatic lesion in the liver. The clinicopathologic features of the hepatic metastases in, and the surgical results for, the 19 patients were analyzed. ResultsThe actuarial 1-year, 3-year, and 5-year survival rates after hepatic resection were, respectively, 77%, 34%, and 34%, and three patients survived for more than 5 years after surgery. Solitary and metachronous metastases were significant determinants for a favorable prognosis after hepatic resection. Pathologically, a fibrous pseudocapsule between the tumor and surrounding hepatic parenchyma was found in 13 of the 19 patients (68%). The presence of a peritumoral fibrous pseudocapsule and a well-differentiated histologic type of metastatic nodule were significant prognostic factors. Factors associated with the primary lesion were not significant prognostic determinants in patients who underwent curative resection of the primary cancer. ConclusionsSolitary and metachronous metastases from gastric cancer should be treated by a surgical approach and confer a better prognosis. A new prognostic factor, the presence of a pseudocapsule, may be helpful in defining indications for postoperative adjuvant treatment.

Is preoperative portal vein embolization effective in improving prognosis after major hepatic resection in patients with advanced-stage hepatocellular carcinoma?

The impact of the use of preoperative portal vein embolization (PVE) on long‐term survival after surgery was evaluated by retrospective analysis of prognostic factors in patients with advanced‐stage hepatocellular carcinoma (HCC) who had undergone hepatic resection with or without PVE.

The effect of FK506 on Warm Ischemia and reperfusion Injury in the Rat Liver

The protective effect of FK506 on hepatocytes against ischemia and reperfusion injury was examined by evaluating the following: the high energy phosphorus metabolism obtained using 31P magnetic resonance spectroscopy (31P-MRS) and the tissue blood flow of the liver in ischemia and the reperfusion process, mitochondrial glutamic oxaloacetic transaminase (m-GOT) and glutamic pyruvic transaminase (GPT), the survival rates of the animals, a histological study and immunohistological staining for intercellular adhesion molecule-1 (ICAM-1) in the liver after ischemia. The rats were treated with FK506 1 mg/kg/day i.m. for 4 days before testing. Ischemia was induced by clamping the hepatoduodenal ligament for 30 min. In31P-MRS, the recovery of the hepatic energy status after ischemia, evaluated by β-ATP/inorganic phosphate (Pi), was significantly better in the FK506 group. It also coincided with the recovery of tissue blood flow monitored with a laser Doppler flowmeter. In the histological examination, the congestion observed in the periportal region of the control group was mild, while there was less induction of ICAM-1 in the endothelial cells of the portal veins and hepatic veins in the FK506 group. From these findings, we concluded that FK506 had a protective effect on hepatocytes against warm ischemia and reperfusion injury, and the mechanism for this could partially be attributed to improved tissue blood flow after ischemia by the modulation of immunological events.

Dihydropyrimidine dehydrogenase (DPD) activity in gastric cancer tissue and effect of DPD inhibitory fluoropyrimidines

BackgroundDihydropyrimidine dehydrogenase (DPD) is an enzyme that catabolizes 5-fluorouracil (5-FU). The effect of DPD inhibitory fluoropyrimidines (DIF) is presumably related to DPD activity. We studied the efficacy of DIF (tegafur + uracil [UFT], tegafur + gimeracil + osteracil [S-1 (TS-1®)]) relative to DPD activity, with other fluoropyrimidines as controls.MethodsThe efficacy of DIF relative to DPD activity was evaluated in 58 gastric cancer patients who received postoperative administration of fluoropyrimidines, consisting of DIF in 42 patients (UFT in 23; S-1 in 19) and non-DIF in 16 patients.ResultsIn patients with low DPD activity (under 40 U/mg protein), curative potential tended to be lower for DIF than for non-DIF, but the survival rate was the same for both. In patients with high DPD activity (40 U/mg protein or more), such a tendency was not detected. In a comparison between those treated with UFT and those treated with S-1, prognosis was better in the latter group, in spite of their predominance of lower curative potentials of B or C. In 27 patients with measurable lesions, a partial response (PR) or higher response occurred in 33% (5/15) of those with low DPD activity, and in 17% (2/12) of those with high DPD activity. In the patients with low DPD activity, non-DIF induced no change (NC) in 17% (1/6), and progressive disease (PD) in the rest. UFT induced PD in all 5 patients, while S-1 induced a response rate of 44% (7/16), with NC in 25% (4/16). In the patients with high DPD activity, on the other hand, non-DIF (n = 3) and UFT (n = 3) induced PD in all the patients, while S-1 induced PR in 33% (2/6) and NC or a higher response in 67% (4/6).ConclusionIt is recommended to use S-1 rather than UFT in patients with high DPD activity. Measurement of DPD was useful in drug selection.

Colo-colic intussusception associated with henoch-Schönlein purpura in adults

Henoch–Schönlein purpura (HSP) is often seen in childhood and is a self‐limiting illness, and complication with intussusception is rare in adults. The case is reported of a 74‐year‐old man who was diagnosed with intussusception with HSP by ultrasonography on day of admission. Conservative therapy was started. However, his abdominal symptoms worsened, so he underwent laparotomy 3 days after admission. Histological study of the resected specimens demonstrated necrosis in the intussuscepted colon induced by HSP vasculitis. Bowel necrosis with intussusception in adult HSP is rare and might easily be overlooked. Thus special attention should be paid to gastrointestinal manifestations and, in an abdominal emergency, timely surgical intervention is life‐saving.

Decrease in aortic distensibility after an extended aortic reconstruction for Marfan's syndrome as a cause of postoperative acute aortic dissection DeBakey type I: A report of two cases

Two cases of Marfans syndrome underwent a reconstruction of the abdominal aorta and descending thoracic aorta. A replacement of the abdominal aorta with visceral arteries as well as a wrapping of the descending thoracic aorta was performed in case 1 while a reconstruction of the descending thoracic aorta and infra-renal abdominal aorta was done in case 2. After the reconstruction, both cases developed acute aortic dissection DeBakey type I. Another reconstruction of the ascending aorta was then urgently performed. Cardiac catheterization after the second operation in case 1 revealed that the distensibility of the aorta had disappeared at the location of the vascular prosthesis while it had also decreased at the wrapped portion, and the maximum dp/dt of the ascending aorta also increased. Increases in the pulse pressure and pulse rate after the first operation were observed in both cases. These hemodynamic changes, which were produced by a decreased distensibility of the reconstructed aorta, increased the mechanical stress to the native aortic wall, and may have been one of the causes of acute aortic dissection DeBakey type I occurring after reconstruction with a prosthesis.

Standardization of thermographic breast cancer detection-role of qualitative findings and quantitative findings

In previous studies, thermographic findings of breast disease were compared with histological findings for evaluating thermographic usefulness. Some researchers tried to create criteria for thermographic diagnosis of breast disease using many kinds of findings. These trials improved the thermographic accuracy rate, but the criteria became too complex. The first purpose of this study is establishing the standard of thermographic breast cancer detection, which is as simple as possible for commonly used thermography. For this purpose, it is clarified which thermographic findings contributed to breast cancer detection. Then, a diagnostic tree for breast thermography is created. In the second part of this paper, the role of several thermographic findings in breast cancer treatment, is discussed.

Resection of the head of the pancreas in three patients with anomalous arrangement or occlusive diseases of the major abdominal visceral arteries

We resected the head of the pancreas in three patients with occlusive diseases or anomalous arrangement of the abdominal visceral arteries. The first patient who was diagnosed with cancer of the head of the pancreas; pancreatoduodenectomy (PD) was performed. Preoperative celiac angiography showed no significant occlusion of the celiac axis, while superior mesenteric arteriography visualized the common hepatic artery, with delayed retrograde filling. At the completion of the PD, an unsuspected atherosclerotic celiac occlusion was identified. Celiac reconstruction was performed. The second patient was diagnosed with cystadenoma of the head of the pancreas and had congenital ostial occlusion of the superior mesenteric artery (SMA), with dilated pancreaticoduodenal (PD) arcades as a celiacomesenteric collateral pathway. Duodenum-preserving resection of the head of the pancreas was performed, with preservation of the PD arcades. The third patient was diagnosed with cancer of the common bile duct, and exhibited a replaced common hepatic artery that arose from the SMA and formed PD arcades. PD was performed, with revascularization of the common hepatic artery. Following surgery, the three patients have done well for 18, 27, and 9 months, respectively. Careful preoperative investigation to identify abnormalities of the visceral arteries is necessary before resection of the head of the pancreas is performed.

Efficacy of Self-Expandable Metallic Stent Inserted for Refractory Hemorrhage of Duodenal Cancer

Because of advances in the technology of gastrointestinal endoscopy and improvements in the quality of stents, it has become routine to place a stent as palliative therapy for malignant gastrointestinal obstruction. On the other hand, stent placement for malignant gastrointestinal hemorrhage has scarcely been reported, although it may be performed for hemorrhage of the esophageal varicose vein. We recently experienced a patient with refractory hemorrhage from an unresectable duodenal cancer who underwent placement of a self-expandable metallic stent (SEMS) and thereafter had no recurrence of the hemorrhage. A 46-year-old man underwent laparotomy to radically resect a cancer in the third portion of the duodenum, which invaded widely to the superior mesenteric vein and its branches and was considered unresectable. After stomach-partitioning gastrojejunostomy was performed, chemotherapy was initiated according to the regimen of chemotherapy of far advanced gastric cancer. One year and 4 months after induction of chemotherapy, gastrointestinal hemorrhage occurred. Upper gastrointestinal endoscopy revealed the hemorrhage oozing from the duodenal cancer, and endoscopic hemostasis, such as injection of hypertonic saline epinephrine and argon plasma coagulation, was unsuccessful. Twenty days after emergence of the hemorrhage, an endoscopic covered SEMS was placed with confirmation by fluoroscopy. Immediately after placement of the stent, the tarry stool stopped and the anemia ceased to progress. The recurrence of the hemorrhage has not been confirmed without migration of the stent. SEMS is an effective hemostatic procedure for malignant refractory hemorrhage.

Usefulness of Orally Administered Own Bile and Inchin-ko-to for the Prolonged Obstructive Jaundice. Report a Case.

症例は65歳の男性で, 下部胆管癌による閉塞性黄疸に経皮経肝胆道ドレナージ (以下, PTBD) を施行. 経腸栄養や利胆剤併用での減黄は不良でPTBD後4週目までの胆汁量は120ml/日, 清水の減黄率b値は-0.0189であった. 遷延性閉塞性黄疸と診断し, 茵陳蒿湯と自家胆汁投与を開始した. 胆汁量は410ml/日と増加し, 黄疸は急速に改善しPTBD後7周目までの清水の減黄率b値は-0.0504となった. 膵頭十二指腸切除術による根治術を施行しトラブルなく退院した.近年, 漢方製薬茵陳蒿湯は胆汁鬱滞に起因する肝細胞のアポトーシスを抑制し, 閉塞性黄疸からの障害肝の回復を促すとの知見が得られており, 閉塞性黄疸の胆道ドレナージ時には自己胆汁投与などとの併用が有用な薬剤と考えられた.