Showing papers in "Surgery Today in 1996"
TL;DR: Chronic constipation was determined to be the most prominent risk factor associated with late recurrence after repair in 109 recurrent incisional hernias repaired and reviewed between 7 and 92 months after the operation.
Abstract: A relatively low success rate in recurrent incisional hernia repair has prompted us to review the effects of certain risk factors on the long-term outcome of our cases. In this study, 109 recurrent incisional hernias were repaired and reviewed between 7 and 92 months after the operation. The recurrence rate was 45.0%. Many conditions that have been implicated as causal factors in the occurrence of incisional hernias were not found to be associated with recurrence after repair. However, chronic constipation was determined to be the most prominent risk factor associated with late recurrence.
97 citations
TL;DR: Overlapping physiologic activities make it unlikely that a single substance is the sole cause of cancer cachexia, and it is hoped that further investigation on other cytokines and their possible relationships with hormones will help to clarify the mechanisms of cancer Cachexia in the near future.
Abstract: The possible role of cytokines in the development of cancer cachexia was reviewed from the literature. Tumor necrosis factor (TNF)-alpha, interleukin (IL)-1, IL-6, interferon (IFN)-gamma and leukemia inhibitory factor (LIF) can elicit many but not all host changes seen in cancer cachexia, including loss of appetite, loss of body weight, and the induction of acute-phase protein synthesis. However, these cytokines are not always demonstrated in the circulation of the cancer patients. The inability to detect circulating cytokines may be due to their low rate of production, their short half-life and rapid clearance from plasma, or their mode of action (autocrine or paracrine). Different cytokines are induced to stimulate the same response. This is very different from hormonal regulation, where a hormone acts on a cell directly through a specific receptor without depending on other mediators. Specific antibodies including anti-IFN-gamma, anti-TNF and anti-IL-6 antibodies, as well as the cyclooxygenase inhibitor indomethacin, have been used to reverse cancer cachexia. Overlapping physiologic activities make it unlikely that a single substance is the sole cause of cancer cachexia. It is hoped that further investigation on other cytokines and their possible relationships with hormones will help to clarify the mechanisms of cancer cachexia in the near future.
84 citations
TL;DR: Monitoring the complement system may be useful for predicting the outcome of patients with sepsis, and the results suggest that the serum levels of C3a,C4a, C5a, CH50, C3, and C4 could serve as indices of the severity of sepsi.
Abstract: The time courses of serum complement levels and the severity of sepsis were compared in two groups of septic patients, one in which the patients survived (surviving group) and one in which they did not (nonsurviving group). The components of the complement system, namely, C3a, C4a, C5a, CH50, C3, C4, and C5, were measured at several points in time after the diagnosis of sepsis had been established. A 2-antibody radioimmunoassay was used to measure C3a, C4a, and C5a; the latex agglutination test was used to measure C3 and C4; nephelometry was used to measure C5; and Meyer's 50% hemolysis method was used to measure CH50. Following the diagnosis of sepsis, the levels of CH50, C3, and C4 were significantly lower in the nonsurviving than the surviving group, while the levels of C3a and C4a were significantly higher in the nonsurviving than the surviving group. The C5a levels were significantly higher in the nonsurviving than the surviving group, although no significant intergroup differences were subsequently noted. These results suggest that the serum levels of C3a, C4a, C5a, CH50, C3, and C4 could serve as indices of the severity of sepsis. Thus, monitoring the complement system may be useful for predicting the outcome of patients with sepsis.
78 citations
TL;DR: The technical aspects of the present method, which has been using when performing the Whipple procedure without any anastomotic complications, may be comparable in terms of technical reliability to other existing methods.
Abstract: We herein describe the technical aspects of our method for end-to-side style pancreatojejunal anastomosis which we have been using when performing the Whipple procedure without any anastomotic complications The method is simple and can be applied wherever an end-to-side pancreatojejunal anastomosis is required It consists of three steps: First, a drainage tube is inserted into the pancreatic duct Second, a direct anastomosis between the pancreatic duct and the mucosal layer of the jejunal loop is performed The third step, which is the unique aspect of our method, is an approximation of the jejunal wall and the pancreatic stump by a one-layer suture technique that allows us not only to reduce the number of sutures but also to eliminate some of the sophisticated manipulations required by other methods The results of our clinical experience have indicated that the present method may be comparable in terms of technical reliability to other existing methods
67 citations
TL;DR: Fine-needle aspiration of the mass revealed many epithelioid cells admixed with multinucleated Langhans-type giant cells, neutrophils, lymphocytes, and stromal cells, leading to a diagnosis of granulomatous mastitis.
Abstract: A 36-year-old woman presented to our hospital with a rapidly growing lump in her left breast. Fine-needle aspiration (FNA) cytology of the mass revealed many epithelioid cells admixed with multinucleated Langhans-type giant cells, neutrophils, lymphocytes, and stromal cells, leading to a diagnosis of granulomatous mastitis. This report describes the clinical course of this patient in whom granulomatous mastitis was successfully treated with corticosteroid therapy. Special reference is made to the usefulness of FNA cytology in the diagnosis and follow-up of this disease.
49 citations
TL;DR: Endoscopic retrograde cholangiopancreatography was the most useful diagnostic procedure and resulted in a correct diagnosis in all but one of the patients investigated by this method and operative endoscopy has also been increasingly used, with good results.
Abstract: Eighty-four patients with choledochocele collected from the world literature and one personal observation are reviewed. The main issues regarding clinical presentation, diagnostic work-up, and the treatment of this uncommon lesion are discussed. Abdominal pain was the most common clinical feature (91% of cases), followed by pancreatitis (38%), nausea or vomiting (35%), and jaundice (26%). In addition, associated lithiasis was found in 43% of the cases. Endoscopic retrograde cholangiopancreatography was the most useful diagnostic procedure and resulted in a correct diagnosis in all but one of the patients investigated by this method. Surgical excision of the duodenal luminal portion of the choledochocele was the treatment most commonly used (65% of cases). In recent years, operative endoscopy has also been increasingly used, with good results.
46 citations
TL;DR: MRI clearly demonstrated that the mass shadow was composed of omental fat herniating into the right thorax through the diaphragmatic hiatus, and is considered to be a useful noninvasive modality for the evaluation of lower anterior mediastinal masses demonstrating fat density on CT.
Abstract: We herein present a patient with Morgagni hernia which was diagnosed by magnetic resonance imaging (MRI). The patient had a progressively enlarging mass in the right cardiophrenic angle on chest roentgenogram. On computed tomography (CT) scans, the mass was revealed to have fat density and therefore was suspected to be either a lipoma or liposarcoma. MRI clearly demonstrated that the mass shadow was composed of omental fat herniating into the right thorax through the diaphragmatic hiatus. MRI is thus considered to be a useful noninvasive modality for the evaluation of lower anterior mediastinal masses demonstrating fat density on CT.
45 citations
TL;DR: Internal stenting of the hepaticojejunostomy and pancreaticoje junostomy was performed in 11 consecutive patients undergoing pancreatoduodenectomy to promote earlier discharge from hospital, and it was proved that all 22 of the stenting tubes had spontaneously fallen out by the 176th postoperative day.
Abstract: Internal stenting of the hepaticojejunostomy and pancreaticojejunostomy was performed in 11 consecutive patients undergoing pancreatoduodenectomy between July 1992, and July 1994, to promote earlier discharge from hospital. Although minor leakage of the pancreaticojejunostomy occurred in 4 patients, this resolved within a short period and all 11 patients were able to be discharged by the 29th postoperative day in good health and without any intubation. Follow-up abdominal X-ray and computed tomography (CT) scans proved that all 22 of the stenting tubes had spontaneously fallen out by the 176th postoperative day. No complication related to the stenting tubes occurred in any of our patients.
45 citations
TL;DR: A 64-year-old woman admitted to the hospital for investigation of gastric submucosal tumor was diagnosed as a malignant granular cell tumor of the stomach from the clinical and pathological findings.
Abstract: We report herein what to our knowledge is the first documented case of a malignant granular cell tumor of the stomach. A 64-year-old woman was admitted to our hospital for investigation of gastric submucosal tumor. Endoscopy disclosed a large hemispherical mass located on the lesser curvature at the gastric antrum with a normal mucosal surface, and computed tomography (CT) revealed a solid tumor about 7 cm in diameter with clear margins. A laparotomy was carried out under the preoperative diagnosis of leiomyosarcoma of the stomach. A tumor was found in the gastric antrum, with extragastric extension to the hepatic hilum, and a distal partial gastrectomy was performed. However, a follow-up CT scan performed 21 months postoperatively revealed a solid tumor of about 10 cm in diameter with clear margins, situated between the liver and the transverse colon. This was subsequently diagnosed as local recurrence and a resection was carried out. Microscopic examination of both the first and second specimens showed that the tumor cells were large and polygonal, with medullary proliferation and finely granular eosinophilic cytoplasm. Mitotic figures were also present. Thus, the lesion was diagnosed as a malignant granular cell tumor of the stomach from the clinical and pathological findings.
43 citations
TL;DR: It is concluded that CD44 v6 could be a reliable prognostic indicator, as well as a predictor of metastatic potential after curative surgery for colorectal cancer.
Abstract: CD44 variant 6 (CD44 v6) is well known as a useful marker of tumor progression; however, its relationship to prognosis has not yet been elucidated. In this study, we investigated the expression of CD44 v6 in colorectal cancer to analyze its relationship to hepatic metastasis as well as to prognosis. Tumor tissues were obtained from 42 patients with colorectal cancer who underwent curative resection with follow-up periods ranging from 5.9 to 71.3 months. There were 21 patients (50%) whose tumors were positive for CD44 v6, with no significant difference between colon and rectal cancer. CD44 v6 staining was significantly related to Dukes' classification as well as to hepatic metastasis. The 5-year survival rate was significantly higher in patients with CD44 v6 negative cancer (84%) than in those with CD44 v6 positive cancer (31%). Thus, we concluded that CD44 v6 could be a reliable prognostic indicator, as well as a predictor of metastatic potential after curative surgery for colorectal cancer.
41 citations
TL;DR: In this study, a 1:1 mixture of the control bile and pancreatic juice was mixed with bovine enterokinase, and the mixture was demonstrated to be reproducibly mutagenic by the Ames test.
Abstract: A reflux of pancreatic juice into the biliary tract due to pancreaticobiliary malfunction has been considered to be an important factor in the development of biliary tract carcinogenesis. It is known that the contents of the biliary tract contain not only activated pancreatic enzymes but also certain mutagens. The purpose of this study was thus to isolate and identify such mutagenic substances. A 1:1 mixture of the control bile and pancreatic juice was mixed with bovine enterokinase (10 mg/ml), and the mixture was incubated at 37 degrees C for 12 h. The mixture was demonstrated to be reproducibly mutagenic by the Ames test. The mutagenic substances in these mixtures, which were separated using organic analysis, were found to be included in the water-soluble fraction and to contain amino acids. Mutagenic substances are thought to have a molecular weight of 1,500-3,500 and to be a complex of low-molecular-weight, stable, mutagenic substances including amino acids and peptides.
TL;DR: TPN-induced fulminant beriberi became evident 4–40 days after the initiation of TPN, and was more likely to develop in patients with malignancies, ulcerative colitis, and short bowel syndrome, as well as in those receiving chemotherapy.
Abstract: Fulminant beriberi, once considered a rare disease, is now being encountered more frequently, yet little is known about its clinical features. This study was undertaken to determine the clinical features of total parenteral nutrition (TPN)-induced fulminant beriberi by reviewing the clinical data on 10 of our own patients who developed this complication, and 33 cases documented in the literature. TPN-induced fulminant beriberi became evident 4–40 days after the initiation of TPN, and was more likely to develop in patients with malignancies, ulcerative colitis, and short bowel syndrome, as well as in those receiving chemotherapy. Although the patients manifested various symptoms, very few developed the classical signs of beriberi or the constant findings seen in alcoholic patients. The severity of metabolic acidosis was extremely high and refractory to bicarbonate administration, but it responded quickly to intravenous (i.v.) thiamine. Thus, rapid i.v. administration of at least 100 mg of thiamine is imperative, and the patient must be transferred to the intensive care unit when TPN-induced fulminant beriberi develops.
TL;DR: The case of a patient in whom a median sternotomy was successfully employed for mediastinal drainage in the treatment of descending necrotizing mediastinitis (DNM) is described, suggesting that Median sternotomy is a satisfactory alternative approach for treatment of this disease.
Abstract: We describe herein the case of a patient in whom a median sternotomy was successfully employed for mediastinal drainage in the treatment of descending necrotizing mediastinitis (DNM). Although most reports describe cervical or thoracotomy approaches, our experience strongly suggests that median sternotomy is a satisfactory alternative approach for treatment of this disease.
TL;DR: The present findings indicate that plasma HGF increases in response to infection or inflammation in patients with systemic inflammatory response syndrome.
Abstract: Interleukin-1 (IL-1), a cytokine released from macrophages by endotoxin stimulation, has been shown to upregulate the genetic expression of the hepatocyte growth factor (HGF). The present study was conducted to determine whether plasma HGF is increased in patients with systemic inflammatory response syndrome (SIRS). The plasma levels of HGF, endotoxin, and beta-glucan were measured in 41 surgical patients without hepatic diseases, 18 of whom had been diagnosed with sepsis, and 33, with nonseptic SIRS. The plasma HGF was found to be significantly increased in the 18 patients with sepsis, at 0.69±0.47 ng/ml (mean ± SD), and in the 23 patients with nonseptic SIRS, at 0.49±0.37 ng/ml, compared to values in 40 normal controls, at 0.10±0.03 ng/ml (P<0.001). No significant correlations were observed between the plasma levels of HGF and endotoxin (r=0.02) or beta-glucan (r=−0.05) in any of the patients; however, plasma HGF was significantly correlated with the WBC count (r=0.34, P<0.05) and with total bilirubin (r=0.45, P<0.01). Plasma HGF was also strongly correlated with alanine transaminase (ALT) in 8 patients with ALT levels higher than 50 U/I (r=0.70), but there was no such correlation in 33 patients with ALT levels of 50 U/I or less (r=0.30). Thus, although the clinicopathologic significance of HGF is not well understood, the present findings indicate that plasma HGF increases in response to infection or inflammation.
TL;DR: It was concluded that the effectiveness of thicker gastric tubes was superior to that of thin tubes, this being most probably attributable to the decreased incidence of suture leakage.
Abstract: This study was conducted to examine the long-term outcome of 500 patients who underwent surgery for cancer of the thoracic esophagus during the past 20 years. Favorable results were obtained with postoperative adjuvant radiation and chemotherapy and there were no surgical deaths in the last 5 years. The mortality rate decreased from 17% prior to 1980 to 5% between 1981 and 1993, this being most probably attributable to the decreased incidence of suture leakage. With respect to changes in surgical techniques, during the initial years we performed intrathoracic anastomosis, after which sternal manubrium resection with anterior mediastinal esophagogastrostomy was carried out. Subsequently, we invented a technique for performing esophagogastrostomy via the posterior mediastinum. The posterior mediastinum was selected as the most physiologic route, based on measurement of tissue oxygen tension. Using blood flow determinations obtained by laser-Doppler velocimetry, we concluded that the effectiveness of thicker gastric tubes was superior to that of thin tubes. Esophagogastrostomy was performed in a shallow field in the cervical region, with the anastomosis ultimately positioned in the superior mediastinum and covered with mediastinal pleura.
TL;DR: Findings show that Gln-supplemented TPN improves mucosal growth and gut Gln uptake after SBR, however, the intestinal production of Cit, which remained low in both TPN groups, may lead to an insufficiency of endogenous Arg synthesis.
Abstract: Glutamine (Gln)-supplemented total parenteral nutrition (TPN) has been shown to improve mucosal adaptation after massive small bowel resection (SBR); however, its influences on intestinal amino acid metabolism remain unknown. In this study, intestinal amino acid flux, circulating plasma aminogram, mucosal glutaminase activity and protein, and DNA content were measured 7 days after massive SBR in rats receiving either standard (Std) or Gln-supplemented TPN. Sham-operated rats and rats fed chow after enterectomy served as controls. The uptake of Gln and the release of citrulline (Cit) by the remaining intestine was significantly decreased, with reduced mucosal glutaminase activity after SBR in the Chow and Std-TPN groups. Glutamine supplementation resulted in significantly increased gut Gln uptake compared with Std-TPN (P 0.05). The subsequent decrease in circulating arginine (Arg) in the Gln-TPN group compared with the Std-TPN group (P<0.05) was attributed to an insufficient exogenous supply. These findings show that Gln-supplemented TPN improves mucosal growth and gut Gln uptake after SBR. However, the intestinal production of Cit, which remained low in both TPN groups, may lead to an insufficiency of endogenous Arg synthesis. Thus, both Gln and Arg may be essential amino acids after SBR.
TL;DR: A 71-year-old man who was initially operated on under the diagnosis of advanced gastric cancer, but was subsequently found to have synchronous lymphoma and early adenocarcinoma of the stomach, confirmed by postoperative pathological examination is reported.
Abstract: We report herein the rare case of a 71-year-old man who was initially operated on under the diagnosis of advanced gastric cancer, but was subsequently found to have synchronous lymphoma and early adenocarcinoma of the stomach, confirmed by postoperative pathological examination. The patient had a history of lymphoma of the left tonsil, and histologically the gastric lymphoma was observed to be of the non-Hodgkin's, diffuse, large-cell type. Conversely, the gastric cancer was early well-differentiated tubular adenocarcinoma of type 0-IIa, according to the Japan Gastroenterological Endoscopy Society classification. The two tumors had collided at the fornix. The relationship between these two tumors is analyzed and the most appropriate methods of diagnosis and treatment are discussed.
TL;DR: Laroscopic-assisted colectomy with lymph node dissection is technically feasible provided that patients are properly selected, and may be indicated not only for colonic carcinoma in the early stage, but also for that with invasion of the muscularis propria or the extramuscular layer.
Abstract: The results of performing laparoscopic-assisted colectomy in 20 patients with invasive carcinoma of the colon were analyzed in this study. The site of the lesion was the right colon in 5 patients, the transverse colon in 1, the left colon in 13, and the rectosigmoid in 1. In 2 patients, the laparoscopic procedure needed to be converted to an open laparotomy. Limited lymph node dissection (R1+, R2) was carried out in 10 patients and extensive node dissection (R3) was carried out in 9 patients. The histological depth of invasion in the 18 patients who underwent laparoscopic-assisted colectomy was the submucosa in 9, the muscularis propria in 2, and the extramuscular layer in 7. There were 3 patients who developed postoperative complications, 1 of whom underwent reoperation due to perforation of the colon. The postoperative course of the patients who underwent laparoscopic surgery was compared with that of a retrospectively selected control group of patients who had undergone open laparotomy. The postoperative recovery of the patients who underwent laparoscopic surgery was significantly faster than that of those who had undergone open laparotomy. Thus, we consider that laparoscopic-assisted colectomy with lymph node dissection is technically feasible provided that patients are properly selected. This procedure may be indicated not only for colonic carcinoma in the early stage, but also for that with invasion of the muscularis propria or the extramuscular layer.
TL;DR: Investigation of the relationship between the initial changes and the kinetic patterns of the markers after therapy and the objective responses suggest that adequate knowledge of the unique kinetics of each marker may help to make a more accurate prediction of the therapeutic responses.
Abstract: Serum carcinoembryonic antigens (CEA), CA 15-3, and tissue polypeptide antigens (TPA) have been used in monitoring the clinical course of patients with breast cancer. However, recent reports have suggested that the serial levels of these markers during therapy do not always correlate with the response to therapy. To clarify the usefulness of the serial combination assay of these markers in monitoring the clinical course of patients during therapy, we investigated the relationship between the initial changes and the kinetic patterns of the markers after therapy and the objective responses. When an increase or decrease of over 20% in these markers is taken to be significant, then the initial changes in all three markers significantly correlated with the therapeutic responses (P<0.01). Five distinct kinetic patterns in the marker levels were observed. A paradoxical kinetic pattern of CEA and CA 15-3 levels — that is, an “initial surge and subsequent drop” — was seen in one-third of the responders. The TPA levels tended to exhibit a “steady decline” pattern in those responders. The sensitivity and specificity of the kinetic patterns to predict the clinical courses were significantly higher than those obtained from the analysis of initial changes. These findings thus suggest that adequate knowledge of the unique kinetics of each marker may help to make a more accurate prediction of the therapeutic responses.
TL;DR: The presence of human β-chorionic gonadotropin was immunohistochemically studied in 123 cases of primary colorectal carcinoma and the positive or negative staining of HCG was demonstrated to be one of the independent prognostic factors.
Abstract: The presence of human β-chorionic gonadotropin (HCG) was immunohistochemically studied in 123 cases of primary colorectal carcinoma using the avidin-biotinperoxidase complex method. Positive staining for HCG was recognized in 45 (36.6%) tumors and a statistical difference was observed between the HCG-positive (n=45) and-negative (n=78) groups concerning the frequency of blood vessel invasion in the primary tumor (P<0.01). The prognosis for patients with HCG-positive carcinoma was thus significantly worse than that for patients with HCG-negative carcinoma (P<0.05). A multivariate analysis using the Cox hazards model demonstrated the positive or negative staining of HCG to be one of the independent prognostic factors. The above findings show that, in addition to various other prognostic factors, the HCG staining status may thus also help in determining the prognosis of patients with primary colorectal carcinoma.
TL;DR: The results suggest that thrombolytic therapy appears to be an attractive nonsurgical alternative for valve thrombosis when the patient's clinical condition is not critical, and thus surgical treatment should only be performed in an emergency on seriously ill patients.
Abstract: Twenty patients underwent nonsurgical and/or surgical treatment for obstruction of mechanical prosthetic valves. The obstructed prosthetic valve was in the aortic position in 11 patients, in the mitral position in 5, and in the tricuspid position in 4. Twelve patients had a bileaflet valve (3 aortic, 5 mitral, 4 tricuspid), and 8 had a tilting disk valve (all aortic). The diagnosis of prosthetic valve obstruction was made by cineradiography and echocardiography. Thrombolytic therapy was instituted in a series of our 10 most recent patients (11 cases), except for one patient with acute renal failure, regardless of the position of the obstructed prosthetic valve. Successful thrombolysis was achieved in 6 cases (54.5%). Six patients required surgical treatment subsequent to either failed or incomplete thrombolysis, and one patient died of congestive heart failure 1 month after surgery. Nonfatal neurologic events occurred in 2 cases (18.2%). A total of 16 patients underwent surgical treatment. Two (12.6%) of the 16 patients died of causes unrelated to the operative procedures before discharge from the hospital. These results suggest that thrombolytic therapy appears to be an attractive nonsurgical alternative for valve thrombosis when the patient's clinical condition is not critical, and thus surgical treatment should only be performed in an emergency on seriously ill patients.
TL;DR: Three cases of right ventricular perforation that were induced by transvenous pacing electrodes were experienced, and middle-aged individuals without myocardial damage, such as patient 3, need only a simple removal and repositioning of the electrode followed by serial echocardiography.
Abstract: We experienced three cases of right ventricular perforation that were induced by transvenous pacing electrodes. The patients were a 72-year-old man who underwent percutaneous transluminal coronary recanalization and angioplasty, an 80-year-old woman who had temporary transvenous pacing for a complete atrioventricular block induced by acute valvular heart failure, and a 44-year-old man who had received a permanent pacemaker. All three patients were treated surgically. The first and second patients demonstrated either cardiac tamponade or hemopericardium necessitating pericardial drainage. Spontaneous hemostasis did not occur in cases 1 and 2, due to either anticoagulant therapy or myocardial degeneration. Such patients require surgical closure of the perforation and pericardial drainage as soon as pericardial effusion is confirmed. In contrast, middle-aged individuals without myocardial damage, such as patient 3, need only a simple removal and repositioning of the electrode followed by serial echocardiography.
TL;DR: Upper mediastinal disection should be carried out in patients with adenocarcinoma in the upper lobe, because skip and undetectable metastasis are not rare, and dissection of the carinal nodes with upper-lobe tumors, and of the upper mediastinum with lower-l lobe tumors, can be omitted.
Abstract: Out of 703 consecutive patients who underwent lung cancer surgery from 1986 to 1994, 562 were studied with an emphasis on lymph node metastasis. Skip metastasis was defined as metastasis to the upper mediastinum without involvement of the carinal, hilar, or intrapulmonary nodes. Twenty-nine patients had skip metastasis, accounting for 17% of the 175 with N2 disease. Except for one patient with a huge tumor, there was no lower-lobe disease. Patients with N2 disease nodes were categorized into the following groups: (1) 32 with false negative N2 that could not be detected macroscopically on the specimen; (2) 64 with true positive N2, detected macroscopically on the specimen; and (3) 79 patients with obvious N2. Positive carinal nodes were found in 12 of 70 N2 patients who underwent upper lobectomy, and in 60 of the (105) remaining N2 patients who had other types of surgery. We conclude that upper mediastinal disection should be carried out in patients with adenocarcinoma in the upper lobe, because skip and undetectable metastasis are not rare. However, dissection of the carinal nodes with upper-lobe tumors, and of the upper mediastinum with lower-lobe tumors, can be omitted when the gross and frozen section findings are negative in the upper mediastinum and both the carinal and hilar nodes.
TL;DR: It is concluded that ventral pancreatic resection can be safely performed and is especially valuable for treating the increasingly frequent adenomas and borderline malignancies in the main pancreatic duct system of the head of the pancreas.
Abstract: The head of the pancreas can be anatomically divided into two sections, one drained by the duct of the Santorini system, and the other drained by the ventral pancreatic duct. This study was undertaken to determine whether independent resection of the ventral pancreas drained by the ventral pancreatic duct could be performed safely and effectively, by employing the following method in four patients. First, the duodenum and pancreas were sufficiently separated preserving the mesoduodenum and the posterior pancreaticoduodenal artery. Next, the main pancreatic duct was divided at the papillary portion, and sectioned at its junction with the duct of Santorini, ensuring preservation of the intrapancreatic bile duct. After the ventral pancreas had been detached from the glistening intrapancreatic bile duct, the ventral pancreas was connected with the dorsal pancreas by only the pancreatic parenchyma. The ventral pancreatic resection was completed following the incision of this border. A pancreatic fistula developed in one patient postoperatively, but this healed within 30 days. The hospital stay after surgery ranged from 35 to 58 days, and a good quality of life was maintained in all four patients. Thus, we conclude that ventral pancreatic resection can be safely performed and is especially valuable for treating the increasingly frequent adenomas and borderline malignancies in the main pancreatic duct system of the head of the pancreas.
TL;DR: A 51-year-old woman admitted to the authors' hospital for further investigation of chest X-ray films which showed multiple shadows that had been growing slowly over 2 years, was pathologically diagnosed as metastasizing leimyosarcoma which was positive for the progesterone and estrogen receptors.
Abstract: A 51-year-old woman was admitted to our hospital for further investigation of chest X-ray films which showed multiple shadows that had been growing slowly over 2 years. Her only symptom was hemosputa. The lesions were suspected of being metastasizing leiomyoma due to her past history of uterine leiomyoma. Just 1 week before undergoing scheduled open lung biopsy, the lung lesions increased remarkably in size and number. A thoracotomy was performed and six of the numerous nodules were removed. The resected specimens were pathologically diagnosed as metastasizing leimyosarcoma which was positive for the progesterone and estrogen receptors. Thus, 1 month postoperatively, a course of medroxyprogesterone (MPA), 600 mg daily, was commenced. The residual lesions in her chest started to diminish, shortly afterward. She has remained well on this MPA regimen for 45 months. The prognosis of patients with metastasizing leiomyosarcoma is poor because of its low sensitivity to chemotherapy; however, some types of leiomyosarcoma are hormone-sensitive. It is therefore important to examine the hormone receptors of excised tumors from patients suspected of having metastasizing leiomyoma or leimyosarcoma.
TL;DR: A resection of the inferior head of the pancreas with an end-to-side pancreaticoduodenostomy can help play a significant role in the management of patients with benign diseases and localized malignant tumors of the Pancreas.
Abstract: We developed a new technique for partial resection of the head of the pancreas with an end-to-side pancreaticoduodenostomy, while preserving the duodenum, the common bile duct, and the upper part of the head of the pancreas around the duct of Santorini. A resection of the inferior head of the pancreas was performed in a patient with an intraductal mucin-producing tumor of the pancreas. This procedure is considered to be appropriate for treating both benign disease and noninvasive malignant disease involving either the uncinate process or the duct of Wirsung, because it removes both the uncinate process and the pancreatic tissue around the duct of Wirsung. We thus believe that a resection of the inferior head of the pancreas with an end-to-side pancreaticoduodenostomy can help play a significant role in the management of patients with benign diseases and localized malignant tumors of the pancreas.
TL;DR: It is essential that continuous and careful assessment of the surgical abdomen is performed when a patient with SLE develops acute abdominal pain, and if a surgical condition cannot be ruled out, a laparotomy should be performed without delay.
Abstract: A 25-year-old Japanese woman who had been suffering from systemic lupus erythematosus (SLE) for 12 years was admitted to our hospital with a suspected diagnosis of peritonitis after suddenly developing severe abdominal pain and distention which could not be relieved by treatment with anodyne. Noninvasive examinations did not provide enough evidence to rule out acute appendicitis, bowel perforation, or ischemia due to vasculitis. Therefore, in consideration of the severity of her uncontrollable abdominal pain, an exploratory laparotomy was performed. The operative findings revealed nonbacterial peritonitis with a large amount of ascites and an edematous small bowel. No perforation of the intestine was found. On post-operative day (POD) 3, the severe abdominal pain redeveloped, but responded well to steroid pulse therapy. Based on the operative findings and her clinical course, the most likely diagnosis was thought to be acute lupus peritonitis. It is often difficult to ascertain whether abdominal pain in an SLE patients is due to lupus peritonitis or to an underlying cause requiring surgery. Thus, it is essential that continuous and careful assessment of the surgical abdomen is performed when a patient with SLE develops acute abdominal pain, and if a surgical condition cannot be ruled out, a laparotomy should be performed without delay.
TL;DR: The case of a 68-year-old man incidentally found to have a lesion in the right lobe of the liver which closely resembled a neoplasm on imaging studies is reported, which revealed a diagnosis of inflammatory pseudotumor.
Abstract: Only 56 cases of inflammatory pseudotumor of the liver have been reported in the world literature since its first documentation in 1953. We report herein the case of a 68-year-old man incidentally found to have a lesion in the right lobe of the liver which closely resembled a neoplasm on imaging studies. Thus, partial hepatic resection was performed and histological examination of the resected specimen revealed a diagnosis of inflammatory pseudotumor. Surgical resection is the preferred treatment for inflammatory pseudotumor of the liver, especially in patients for whom a definite histologic diagnosis cannot be made preoperatively or by intraoperative frozen sections. In fact, most of the patients reported in the literature recovered uneventfully after local resection without any postoperative complications, as did our patient.
TL;DR: Cases of two patients with major venous anomalies associated with abdominal aneurysmectomy are reported, one being an isolated left-sided vena cava and the other, a retroaortic left renal vein, and the clinical significance is discussed.
Abstract: We report herein the cases of two patients with major venous anomalies associated with abdominal aneurysmectomy, one being an isolated left-sided vena cava and the other, a retroaortic left renal vein, and discuss the clinical significance of such anomalies. In the first patient, an isolated left-sided vena cava was correctly diagnosed preoperatively by contrast-enhanced computed tomography (CE-CT) and digital subtraction angiography (DSA) which revealed that the vena cava crossed the normal portion of the aorta and the right renal vein ran cephalad. In the second patient, a retroaortic left renal vein was also preoperatively diagnosed with CE-CT and DSA. In both patients, dissection was performed, taking care to avoid injury to anomalous venous tributaries, and graft replacement for abdominal aneurysm was successfully carried out. Thus, careful preoperative evaluations using such imaging techniques as CE-CT, DSA, and venographic studies, are important for establishing the presence of an associated venous anomaly preoperatively to ensure the success of abdominal aneurysmal surgery.
TL;DR: The mechanism of cellular injury caused during hepatic ischemia and subsequent reperfusion resulting from certain types of surgery is presented, with special reference to the xanthine-xanthine oxidase system and the activation of neutrophils and macrophages.
Abstract: It is well known that ischemia causes functional and structural damage to liver cells, and that the status of energy metabolism provides an important means of assessing the functional viability of the ischemic organ. However, the specific sequence leading to ischemic liver cell injury is not yet fully understood; therefore, it is clinically and pathophysiologically important to elucidate the mechanism of cellular injury during hepatic ischemia and subsequent reperfusion. Whereas the conventional view attributes this injury process to the ischemia itself, recent studies have demonstrated that a variable but often substantial proportion of this injury is caused by reactive oxygen metabolites that are generated at the time of reperfusion. This article presents an outline of the mechanism of cellular injury caused during hepatic ischemia and subsequent reperfusion resulting from certain types of surgery, with special reference to the xanthine-xanthine oxidase system and the activation of neutrophils and macrophages.