Yukimitsu Kawaura

Clinical study of chronic pancreatitis with focal irregular narrowing of the main pancreatic duct and mass formation: comparison with chronic pancreatitis showing diffuse irregular narrowing of the main pancreatic duct.

Introduction Main pancreatic duct (MPD)-narrowed chronic pancreatitis (CP) may be an autoimmune abnormality. It also has been called autoimmune pancreatitis and sclerosing pancreatitis. It is unclear whether cases with focal pancreatographic changes are part of the same clinical entity as cases with diffuse MPD changes. Aim and Methodology We reviewed seven cases of chronic pancreatitis (CP) with focal narrowing of the main pancreatic duct (MPD), evidenced by endoscopic retrograde cholangiopancreatography (ERCP), and swelling of one or two segments of the pancreas, evidenced by ultrasonography (US) /computed tomography (CT), and indicated the clinicopathologic features of focal-type MPD-narrowed CP. Results The patient group comprised six men and one woman, and their age range was 28–75 years, with a mean of 63.7 years. Affected sites were in the head in two patients, the body in one patient, the tail in one patient, and the body and tail in three patients; ERP showed narrowing in six patients and obstruction in one. Stricture of the lower portion of the common bile duct (CBD) that caused obstructive jaundice was shown by ERC in two cases in which the pancreas head was affected. In all six patients, a dynamic study by CT or MRI homogeneously showed delayed enhancement of involved segments of the pancreas. Serum levels of pancreatic enzyme were elevated in five patients, but only one subject had pancreatitis-like epigastric pain. Serological evidence suggestive of autoimmune abnormality was detected in only three patients with hypergammaglobulinemia (≥2.0 g/dL) or positive titers of antinuclear antibody (ANA; ≥80). Histological assessment was available for five patients, who characteristically had dense lymphocytic or plasmocytic infiltration with severe fibrosis that caused luminal narrowing. The clinical, serologic, and histologic findings as described above were comparable to those for 12 CP patients with diffuse narrowing of the MPD, diagnosed during the same period. Surgical resection was performed in 5 patients, in 2 of whom a similar inflammatory process recurred in the remnant head of the pancreas, whereas pancreatitis no longer developed in the other 3 patients. One patient was initially treated with steroids, with clinical remission, although there was neither hypergammaglobulinemia nor positive ANA. Conclusion These results indicate that CP with focal narrowing of the MPD is part of the same clinical spectrum as CP with diffuse narrowing of the MPD, and whether the distribution is diffuse or focal seems to be related to the stage or the extent of the disease. It is therefore important to recognize the possible existence of this focal variant to avoid unnecessary surgery.

Clinical management of intraductal papillary mucinous tumors of the pancreas based on imaging findings.

The aim of this study was to assess the imaging findings of pathologically proven intraductal papillary-mucinous tumors of the pancreas and the natural history of follow-up cases, and to optimize the therapeutic management of patients with these tumors according to their imaging findings. All nine patients with main duct type tumors were histologically diagnosed as having adenocarcinoma or adenoma, with no hyperplastic lesion. The images failed to discriminate between the two histologic types. In 26 patients with branch duct type tumors, all but one with intraductal mural nodules or tumors of ≧30 mm had adenocarcinoma or adenoma, regardless of the caliber of the main duct. Of the nine patients with tumors < 30 mm and no mural nodules, three had adenoma, and six had hyperplasia. All of four patients had hyperplasia, with the additional caliber of the main duct being < 6 mm. In a series of 23 cases in which the patient was followed-up, no apparent progression was found in 17 patients who had no mural nodules and tumors of < 30 mm. Given these results, patients with main duct type tumors, and those with branch duct type tumors showing mural nodules or a tumor diameter of ≧30 mm, are at high risk of developing neoplasms, including adenocarcinoma, for which surgical resection should be considered, whereas those patients with tumors < 30 mm and no mural nodules can be followed.

Tissue oxygen saturation during colorectal surgery measured by near-infrared spectroscopy: pilot study to predict anastomotic complications.

We investigated the relation between tissue oxygen saturation measured by near-infrared spectroscopy (NIRS) and anastomotic complications associated with colorectal surgery. A series of 20 patients with colorectal cancer underwent radical surgery with enteric anastomosis. Measurements of tissue oxygen saturation (StO2) were performed at both the proximal and distal portions of the anastomotic site; in cases of anterior resection, we measured StO2 only in the proximal portion. Two anastomotic complications (one leakage, one stenosis) occurred in the 20 cases. The StO2 in patients with anastomotic complications was 58.0%, and that in patients without complications was 71.0%. Altogether, 18 patients had StO2 values > 66%, and none of them had anastomotic complications. In contrast, 2 patients had StO2 values < 60%, and both had anastomotic complications. The StO2 of the anastomotic site can be safely and reliably measured by NIRS during colorectal surgery. Low StO2 on both sides of the anastomosis may indicate an increased risk of anastomotic complications. Further study is needed to determine the cutoff value for StO2 required to prevent serious complications.

Immunohistochemical study of p53, c-erbB-2, and PCNA in Barrett's esophagus with dysplasia and adenocarcinoma arising from experimental acid or alkaline reflux model

Purpose. An immunohistochemical study of p53, c-erbB-2, and proliferating cell nuclear antigen (PCNA) in Barretts esophagus with dysplasia and adenocarcinoma, arising from experimental acid or alkaline reflux, was performed in dogs. Methods. Cardiectomy was performed in group A (n = 26) as an acid reflux model, and total gastrectomy was performed in group B (n = 24) as an alkaline reflux model. After surgery, the esophageal mucosa was observed and biopsied endoscopically every 3 months over a period of 6 years. Immunohistochemical staining of p53, c-erbB-2, and PCNA was performed, using biopsied specimens. Results. In group A, Barretts esophagus developed in 14 of the 26 dogs. Low-grade dysplasia occurred in 5 of the 26 dogs, and in 1 of these 5 dogs, it developed into high-grade dysplasia. In this animal, adenocarcinoma arose 63 months after the operation. In group B, Barretts esophagus developed in 10 of the 24 dogs. Low-grade dysplasia was observed in 4 of the 24 dogs. In 1 of these 4 dogs, the dysplasia became high-grade and adenocarcinoma occurred 66 months after the operation. In group A, PCNA was positive in adenocarcinoma; the PCNA labeling index (LI) was 58. c-erbB-2 and p53 were negative in all animals in group A. In group B, PCNA was positive in Barretts esophagus with high-grade dysplasia and adenocarcinoma; the PCNA LI was 77. p53 was positive in adenocarcinoma. c-erbB-2 was negative in adenocarcinoma. Conclusions. The results of this study provided evidence of the dysplasia-carcinoma sequence arising from alkaline reflux, as well as from acid reflux. To the best of our knowledge, this is the first report of the use of an alkaline reflux model and a 6-year study using dogs to observe the course of Barretts esophagus.

EFFICACY OF MULTI-SLICE COMPUTED TOMOGRAPHY CHOLANGIOGRAPHY BEFORE LAPAROSCOPIC CHOLECYSTECTOMY

Background:  Bile duct injury is one of the serious surgical complications of laparoscopic cholecystectomy (LC). Clear biliary tract imaging to detect the anomaly of the bile ducts before operation is thought to be useful to prevent this complication. The objective of this study was to investigate the preoperative feasibility of using multi‐slice computed tomography scanning after drip infusion cholangiography–computed tomography (DIC‐CT) for LC.

DESMOID TUMOR OF THE CHEST WALL FOLLOWING CHEST SURGERY : REPORT OF A CASE

Desmoid tumors of the chest wall following chest surgery are a rare occurrence. A case of this disease is reported herein together with a review of the literature. A 74-year-old man, who had previously undergone a right lower lobectomy for squamous cell carcinoma of the lung, was referred to our hospital with an abnormal shadow on his chest X-ray. The tumor, located in the right lateral chest wall, was successfully resected by an aggressive, wide extirpation, and a final diagnosis of a desmoid tumor originating in the chest wall was made. When following up patients after surgery for lung cancer, the possibility of desmoid tumors developing in the incised chest wall should therefore be kept in mind.

Gluteal abscess caused by perforating rectal cancer: case report and review of the literature.

An unusual case is described in which an abscess developed remote from a carcinoma of the rectum. A 52-year-old Japanese man developed a gluteal abscess six months after radiation therapy for unresectable carcinoma of the rectum. This case is presented with a review of the literature. Perforating carcinoma of the colon and rectum with abscess formation is best treated by preliminary total diversion colostomy and local drainage of the abscess. However, the mortality rate is still high.

Brain damage after deep hypothermia in dogs.

Histopathological and succinic acid dehydrogenase (SAD) activity changes, and the electron spin resonance (ESR) were examined in the brains of dogs exposed to various hypothermic conditions. A simple hypothermic cardiac arrest of 5 min duration occurred in the group subjected to 28°C, and normal SAD activity was noted in dogs exposed to 1-hour extracorporeal circulation under normothermia. In cases of a hypothermia below 28°C, a decrease in enzyme activity, marked histopathological changes and the disappearance of the ESR signal were observed. In dogs killed immediately after induction of 20°C hypothermia, the histopathological changes were primarily ischemic in nature, while in dogs killed at 1–12 month intervals after the experiments, irreversible gliosis was dominant. Our findings suggest that, to avoid brain damage under conditions of deep hypothermic circulatory arrest, the critical range is between 26–28°C for rectal, and approximately 28–30°C for brain temperature.

Primary mediastinal germ cell tumor in a middle-aged woman: case report and literature review.

Although primary mediastinal germ cell tumors are found much more frequently among young males than among other people, we recently encountered a middle-aged woman with the disease. The patient was a 59-year-old woman who complained mainly of anterior chest pain. Chest CT scans revealed a nonhomogeneous mass measuring 7 x 7 cm in the anterior mediastinal area, accompanied by signs suggestive of mediastinal invasion of the tumor. Reduction surgery was performed. The pathologic diagnosis was mediastinal dysgerminoma. The patient received postoperative radiochemotherapy but died due to liver metastasis 11 months after surgery.

A case of metastatic lung carcinoma in the thyroid gland presenting as a goiter

Abstract This report concerns a patient with primary lung cancer that had metastasized to the thyroid, and who was treated with a single-stage surgical operation. The thyroid gland has generally been considered to be an infrequent site for metastasis of primary carcinomas of other organs, but metastatic thyroid disease has been found with moderate frequency in postmortem studies. Although there is no clear consensus regarding the role of surgery in the treatment of metastatic disease of the thyroid, the postoperative course of our patient prompts us not to advocate thyroidectomy in cases of advanced and aggressive tumors such as carcinoma of the lung. Adequate diagnosis and treatment of thyroid metastasis should be considered, after which an aggressive surgical approach may be recommended for selected patients.