Yutaka Kashiwagi

Perioperative immune responses in cancer patients undergoing digestive surgeries

BackgroundTh1/Th2 cell balance is thought to be shifted toward a Th2-type immune response not only by malignancy but also by surgical stress. The aim of this study was to estimate perioperative immune responses with respect to the Th1/Th2 balance in patients with gastrointestinal cancer.MethodsNinety-four patients who underwent abdominal surgeries were divided into three groups: gastric resection (n = 40), colorectal resection (n = 34) and hepatic resection (n = 20). Twelve patients undergoing laparoscopic cholecystectomy and 20 healthy subjects were served as control groups. Intracellular cytokine staining in CD4+ T lymphocytes was identified to characterize Th1/Th2 balance. Th1/Th2 balance was evaluated before operation and until postoperative days (POD) 14.ResultsThe preoperative Th1/Th2 ratio was significantly lower in patients with malignancy compared with control. The Th1/Th2 ratio of patients in all groups decreased significantly postoperatively. Th1/Th2 balance on POD 2 in patients with malignancy was significantly decreased compared to patients with laparoscopic cholecystectomy, but there were no significant differences among the four groups on POD 14.ConclusionPatients with malignancy showed an abnormal perioperative Th1/Th2 balance suggesting predominance of a type-2 immune response. Major abdominal surgeries induce a marked shift in Th1/Th2 balance toward Th2 in the early postoperative stage.

Can three-dimensional helical CT cholangiography before laparoscopic cholecystectomy be a substitute study for endoscopic retrograde cholangiography?

The study investigated the usefulness of three-dimensional helical computed tomography (3D-CT) before laparoscopic cholecystectomy (LSC) when compared with that of endoscopic retrograde cholangiography (ERC). Forty-five patients referred for LSC, who had undergone 3D-CT cholangiography and ERC simultaneously, participated in the study. Endoscopic retrograde cholangiography and 3D-CT cholangiography were compared in each patient with regard to opacification of the biliary tree, stones, and anatomic variations. Three-dimensional helical CT cholangiography and ERC imaging for predicting operative difficulties in LSC also were compared. The common bile duct and cystic duct were shown in the patients by the images, but the gallbladder was shown in 43 patients (96%) with use of 3D-CT cholangiography and in 36 patients (80%) with use of ERC. A third or more peripheral branches were shown completely with use of 3D-CT cholangiography in 33 patients (73%) and in 32 patients (71%) with use of ERC. Cystic duct stones were found in two of three patients with use of 3D-CT cholangiography and ERC. Common bile duct stones in five of seven patients were detected with use of 3D-CT cholangiography, but all of the common bile duct stones were detected with use of ERC. Anatomic variations of the bile duct were shown in three of four patients by 3D-CT cholangiography and in all patients with use of ERC. No significant differences in findings of the angle of bifurcation and presence of Heister valves between operative easy and complex cases were shown by 3D-CT cholangiography and ERC, despite the more accurate assessment of the cystic duct anatomy with use of 3D-CT cholangiography than with use of ERC. Three-dimensional helical CT cholangiography is useful clinically in preoperative assessment of biliary anatomy, but it is not reliable in the detection of common bile duct stones, and it is not helpful in predicting technical difficulty during LSC.

Gardner's Syndrome Associated with Giant Desumoid Tumor in the Submandibular Region, Report of a Case.

開口障害の原因となった左下顎部の巨大デスモイド腫瘤を摘出し, 術後にsulindacを経口投与して経過良好なガードナー症候群の1例を経験したので報告する.症例は14歳の女性. 左下顎部の腫瘤により開口障害が出現し来院. MRI検査では左下顎部にT1で低信号, T2でやや高信号の巨大な腫瘤を認め, 咽頭および舌根部は圧排されていた. 大腸内視鏡検査ではポリープ5個のみ認めた. 腫瘤摘出術を施行したが咽頭深部で腫瘤が残存したため術後sulindacを投与した. 開口障害は改善し, 経過は良好である.ガードナー症候群では大腸癌, 十二指腸腫瘍, デスモイド腫瘍が大きな死因をしめるが, デスモイド腫瘍は術後の腹壁, 腹腔内に生じることが多く, 手術既往のない下顎部発症はまれである. sulindacによる大腸腺腫の減少, デスモイド腫瘍の縮小が報告されており, 腫瘤摘出術後のsulindac投与により予後, QOLが向上する可能性があると思われた.