Superior mesenteric vein resection without reconstruction in pylorus-preserving pancreatoduodenectomy for pancreatic head cancer

The prognosis of pancreatic cancer is poor, even in resectable patients. The reason for this poor prognosis is partly due to local invasion of the tumor into the tissues around the pancreas. Pancreatic head cancer usually invades the mesentericoportal veins, so the combined venous resection is usually performed during pancreatoduodenectomy for the purpose of obtaining a negative surgical margin. We performed pancreatoduodenectomy for lower pancreatic head cancer together with superior mesenteric vein resection without reconstruction in two patients, after confirming adequate portal venous flow and small intestinal congestion, This is the first report of pancreatoduodenectomy combined with superior mesenteric vein resection without reconstruction for the purpose of obtaining a wide surgical margin.     

Bone Marrow Cytogenetic Complete Remission Achieved by Interferon-α Plus Cytarabine Ocfosfate Therapy in a Patient With Chronic Myelogenous Leukemia During Extramedullary Blast Crisis

We report a case of chronic myelogenous leukemia (CML) in which the bone marrow achieved cytogenetic complete remission (CCR) achieved by treatment with interferon-alpha and oral cytarabine ocfosfate after extramedullary blast crisis. A 51-year-old Japanese man diagnosed with CML was treated with interferon-alpha. Two months later; lymph node swellings developed in his neck and inguinal regions. Lymph node biopsy revealed the infiltration of blast cells showing bcr-abl fusion signal by fluorescence in situ hybridization analysis. Bone marrow aspiration and cytogenetic analysis demonstrated that his bone marrow was still in the chronic phase, with minor cytogenetic response. Continuing interferon-alpha for 6 months in combination with oral cytarabine ocfosfate resulted in the disappearance of the neck lymph node swellings followed by CCR in the bone marrow. However, rapid reenlargement of the neck and inguinal lymph nodes was noted 2 months after CCR despite maintaining medullary remission with major cytogenetic response. Finally, medullary crisis was noted 13 months from the initial development of the extramedullary crisis. This case suggests that interferon-alpha plus cytarabine ocfosfate therapy may be of benefit in the treatment of extramedullary blast crisis of CML.     

Phenolic glycolipid-1 (PGL-1) in Buruli ulcer lesions. First demonstration by immuno-histochemistry

Buruli ulcer, caused by Mycobacterium ulcerans, is emerging as the third most common mycobacterial disease after leprosy and tuberculosis in some tropical regions. Although a toxin of the polyketide family is central to the pathogenesis of the disease, there are still several parameters that need clarification. Among them and of crucial interest are the curative drug treatment and the test for early detection of the disease. In this study, we used mouse monoclonal antibodies, raised against synthetic sugars of the terminal trisaccharide of M. leprae PGL-1, to detect the immunoreactivity of this antigen in tissue infected with M. ulcerans. Thirty specimens of skin tissue from Buruli ulcer patients (3 plaques, 10 nodules, 1 ulcerated nodule, 7 deep ulcer beds and 9 ulcers in healing) were obtained from Ghana. Eighty-three percent of the submitted cases were compatible with the lesions of Buruli ulcer. AFB were positive in 33% of plaques, 40% of nodules, 44% of actives ulcers and 22% of the ulcer in healing stage. Immunohistochemically, phenolic glycolipid-1 (PGL-1) was detected in all AFB-positive cases. This observation implies that Mycobacterium ulcerans may express an M. leprae PGL-1-like substance and should tentatively emulate research to further characterize such a substance. The search for an early diagnostic tool for the Buruli disease may benefit from such investigations.     

Antiproteinuric effects of combined antihypertensive therapies in patients with overt type 2 diabetic nephropathy.

Combined antihypertensive therapy plays a crucial role in achieving targeted blood pressure reductions and renoprotection. We therefore compared the antihypertensive and antiproteinuric effects of combined therapy with either a calcium channel blocker (CCB) plus an angiotensin II receptor blocker (ARB) or an angiotensin converting enzyme inhibitor (ACE-I) plus an ARB in patients with type 2 diabetes mellitus complicated by overt nephropathy and mild to moderate hypertension. After a 12-week dietary control period, diabetic patients with mildly to moderately impaired renal function were randomly assigned to either a CCB (amlodipine 5 mg once daily) or an ACE-I (temocapril 2 mg once daily) for 12 weeks (monotherapy period). Both groups then received add-on therapy with an ARB (candesartan 4 mg once daily) for an additional 12 weeks. During the monotherapy period, blood pressure was decreased equally well in both groups. Daily urinary protein excretion remained unchanged in the CCB-treated group (control period, 4.0 +/- 1.8 g/day vs. CCB period, 4.1 +/- 1.9 g/day; ns; n = 8), but decreased in the ACE-I-treated group (control period, 4.3 +/- 1.8 g/day vs. ACE-I period, 3.5 +/- 1.7 g/day; p < 0.05; n = 9). After the combined therapy period, blood pressure was decreased to the same degree in both groups. Although ARB plus CCB significantly reduced urinary protein excretion (to 3.5 +/- 1.5 g/day; p < 0.05 vs. control period; n = 8), a more profound reduction was achieved with ARB plus ACE-I (to 2.6 +/- 1.3 g/day; p < 0.01 vs. control period; n = 9). Monotherapy with the ACE-I increased the serum potassium concentration, and this elevation was sustained after addition of the ARB. In contrast, the serum potassium concentration was not influenced by monotherapy with the CCB, but was significantly increased after addition of the ARB. A decreased hematocrit was observed in the ARB plus ACE-I group. The present study suggests that combined antihypertensive therapy with either a CCB plus an ARB or an ACE-I plus an ARB exerts an antiproteinuric effect in patients with type 2 diabetic nephropathy with mildly impaired renal function. Although the latter combination had a more profound effect, it was associated with an increased serum potassium concentration and worsening of renal anemia. Thus, the combination of a CCB and an ARB should be the first line antihypertensive therapy in those with overt diabetic nephropathy. The long-term efficacy of these combined antihypertensive therapies will need to be further addressed in a future study.     

Usefulness of color Doppler ultrasonography (CDUS) and three-dimensional spiral computed tomographic angiography (3D-CT) for diagnosis of unruptured abdominal visceral aneurysm

A 52-year-old Japanese man was transferred to our center where screening by means of ordinal ultrasonography and color Doppler ultrasonography revealed an abdominal visceral aneurysm. Although we were unable to confirm the site of this aneurysm by means of ultrasonographic examination, thin-sliced contrast enhanced computed tomography and three-dimensional spiral computed tomographic angiography showed that the aneurysm was situated at the root of the splenic artery. Transcatheter arterial embolization of the aneurysm was performed by metallic coil with occlusion of the main route of the splenic artery because it was technically difficult to embolize the aneurysm alone while preserving the main splenic arterial flow. Angiography of the celiac trunk after transcatheter arterial embolization showed no enhancement of the aneurysm or splenic artery, and superior mesenteric arteriography after transcatheter arterial embolization showed enhancement of the spleen by collateral circulation from the superior mesenteric artery. One year after transcatheter arterial embolization, repeated contrast enhanced computed tomography revealed the enhancement of the spleen, and color Doppler ultrasonography revealed no blood flow in the aneurysm. Color Doppler ultrasonography and 3D-spiral computed tomographic angiography are both useful for diagnosis of a visceral aneurysm, for confirmation of its exact site and form, and for deciding upon a treatment procedure.     

Combined effects of an anticoagulant and a lipid-lowering agent on the prevention of steroid-induced osteonecrosis in rabbits

OBJECTIVE: To investigate the effects of combination treatment with an anticoagulant (warfarin) plus a lipid-lowering agent (probucol) on the prevention of steroid-induced osteonecrosis (ON) in rabbits. METHODS: Adult male Japanese white rabbits were injected once intramuscularly with 20 mg/kg of methylprednisolone acetate into the right gluteus medius muscle. The rabbits were then divided into 4 groups and treated as follows: one group received warfarin plus probucol (WP; n = 25), one received probucol alone (PA; n = 30), one received warfarin alone (WA; n = 26), and one received no treatment (nonprophylactic [NP]; n = 20). Two weeks after the steroid injection, the femora and humeri were examined histopathologically for the presence of ON. The sizes of the bone marrow fat cells were examined morphologically. Hematologic examinations were performed before and after the steroid injection. RESULTS: The incidence of ON in the WP group (5%) was significantly lower than that observed in the NP group (70%). While the incidence rates of ON in the PA (38%) and WA (33%) groups were also significantly lower than that in the NP group, they were significantly higher than that observed in the WP group. The sizes of the bone marrow fat cells in both the WP (53.5 +/- 4.1 microm) and the PA (52.0 +/- 5.0 microm) groups were significantly smaller than those in the NP group (60.0 +/- 4.0 microm). We also observed a prolongation of the prothrombin time and a reduction in the plasma lipid levels in the WP group during the study. CONCLUSION: This study experimentally confirmed that the combined use of an anticoagulant and a lipid-lowering agent helps prevent steroid-induced ON in rabbits.     

A case of multiple myeloma presenting as giant chest wall tumors with calcification]

A 60-year-old man was admitted for investigation of an abnormality detected in chest radiography: a giant tumor with calcification in the right middle lung field. A computed tomography (CT) scan revealed multiple tumors with calcification on the posterior chest wall. Histological analysis of the tumor specimen obtained by surgical biopsy demonstrated an increasing number of plasma cells accompanied with the deposition of amyloid. A bone marrow biopsy contained over 50% of plasma cells. We therefore diagnosed these tumors as multiple myeloma. It has been reported that multiple myeloma is usually characterized by osteolytic lesions; osteosclerotic changes are rare. Multiple myeloma should be taken into account as one of the causes of a chest wall tumor even if it is diffusely calcified.     

Coexistence of Marfan-like Connective Tissue Disease with Morphologic Left Ventricular Non-compaction

We treated a man with co-incident Marfan-like connective tissue disease with morphologic left ventricular non-compaction (LVNC). He underwent valve-sparing aortic root replacement because of aortic root dilation at 43 years old. Pathological findings of the aorta revealed cystic medio-necrosis, consistent with Marfan syndrome. He developed congestive heart failure caused by LVNC at 47 years old. His daughter had scoliosis, and he had several physical characteristics suggestive of Marfan syndrome. We herein report a rare case of a patient who had Marfan-like connective disease with an LVNC appearance.     

Gastrin receptors in the human gastrointestinal tract and pancreas

The specific binding of¹²⁵I-labeled gastrin-17 was studied in samples of human gastric mucosa, duodenal mucosa, colonic mucosa or pancreatic tissue obtained surgically. With regard to gastric fundic mucosa, the criteria for receptor binding were studied, and saturability, high affinity, tissue specificity and hormone specificity were demonstrated. The dissociation constant for gastric fundic mucosa was 1.6 x 10^-9M, and the binding capacity was 15 fmol/mg protein. Tissue specificity studies revealed a high degree of gastrin receptor binding in human gastric fundic mucosa, duodenal mucosa and pancreas, whereas antral mucosa and colonic mucosa demonstrated a low degree of binding.     

Effect of Enprostil on Omeprazole-Induced Hypergastrinemia and Inhibition of Gastric Acid Secretion in Peptic Ulcer Patients

This study was performed to examine the effectsof additional enprostil administration onhypergastrinemia and gastric acid suppression induced byomeprazole. Serum gastrin concentrations were measured in 10 peptic ulcer patients (six Helicobacterpylori-positive and four Helicobacter pylori-negativepatients) before treatment, after two weeks ofomeprazole (20 mg/day), and after two weeks ofomeprazole and enprostil (50 g/day). The additionalacid inhibitory effect of enprostil was evaluated by24-hr intragastric pH measurements in five healthyHelicobacter pylori-negative volunteers. Afteromeprazole treatment, the serum gastrin level ofHelicobacter pylori-positive patients (3.5-fold ofcontrol) was markedly higher than that of Helicobacterpylori-negative patients (1.7-fold of control).Additional treatment with enprostil suppressed serumgastrin levels to 0.4-fold and 0.7-fold of omeprazoletreatment levels in Helicobacter pylori-positive andHelicobacter pylori-negative patients, respectively. In healthy volunteers, median pH recordedduring the nonmeal daytime interval increasedsignificantly with additional enprostil. Thus, enprostilreduces undesirable omeprazole-induced hypergastrinemia, especially in Helicobacter pylori-positivepatients, and effectively suppresses acidsecretion.