Marginal ulceration after pylorus-preserving pancreaticoduodenectomy

Marginal ulceration is a serious problem after both standard pancreaticoduodenectomy (PD) and pylorus‐preserving pancreaticoduodenectomy (PPPD). The relationship between this complication and the method of reconstruction after PPPD was analyzed in this study. Patients who underwent standard PD (n = 72) or PPPD (n = 28) in the 20‐year period from 1978 to 1997 were retrospectively reviewed. After PPPD, 4 patients (14.3%) developed marginal ulceration on the jejunal side of the duodenojejunal anastomosis, while none of the patients had marginal ulceration after standard PD. The marginal ulcer occurred in 3 of 14 patients treated with the Roux‐en‐Y method, and in 1 of 9 treated with pancreatogastrostomy. In the Roux‐en‐Y method, the anal jejunal loop anastomosed to the bulb was directly exposed to gastric juice without neutralization by pancreatic juice from the oral jejunal limb. Of the 4 patients with marginal ulceration, 2 of those treated by the Roux‐en‐Y method required gastrectomy; the other 2 patients were treated medically. Our analysis of the literature showed that the Roux‐en‐Y method had the highest incidence of marginal ulcerations. The gastrointestinal reconstruction method without a mixture of gastric juice and pancreatic juice may be a causal factor in the marginal ulceration that occurs after PPPD. In reconstruction after PPPD, we should not create a jejunal loop that is exposed to gastric juice alone.     

Bile leak test by indocyanine green fluorescence images after hepatectomy

Bile leak remains a serious complication after hepatectomy. The conventional leak test by intrabiliary injection of normal saline solution is not sensitive. The authors present a new bile leak test using indocyanine green (ICG) fluorescence. After hepatic transection, ICG solution (.05 mg/mL) was intrabiliarily injected through a transcystic tube under distal common bile duct clamping, and fluorescent images were visualized using an infrared camera system. The ICG leak test was performed in 27 patients undergoing hepatectomy without biliary reconstruction. Bile leaks were intraoperatively found in 8 patients and fixed, resulting in no postoperative leaks. There was no adverse reaction to ICG. In contrast, postoperative bile leaks occurred in 2 of 32 patients who received the conventional leak test with normal saline solution between April 2007 and March 2008. The new bile leak test by ICG fluorography is useful to prevent postoperative bile leak.     

Portal vein thrombosis after splenectomy successfully treated by an enormous dosage of fibrinolytic agent in a short period: Report of two cases

Portal vein thrombosis (PVT) after splenectomy in a patient with portal hypertension occurs with unusually high frequency. Recently, two patients with PVT following splenectomy were treated by fibrinolytic therapy with an enormous dosage of urokinase (UK) in a short period. PVT was quickly dissolved without side effects and the patients are now doing well without any recurrence of PVT. Therefore, when there is no evidence of bowel infarction, fibrinolytic therapy with an enormous dosage of UK over a short period is deemed to be both effective and essential as a conservative therapy for PVT.     

Clinicopathological features of hepatocellular carcinomas (HCCs) arising in patients without chronic viral infection or alcohol abuse: a retrospective study of patients undergoing hepatic resection

Background This study was carried out to clarify the etiology and clinicopathological features of hepatocellular carcinomas (HCCs) arising in patients without chronic viral infection or alcohol abuse.Methods HCC patients who underwent resection were divided into three groups: a non-B non-C (NBNC) group (n = 13), who were seronegative for hepatitis B surface antigen (HBs Ag) and anti-hepatitis C antibody (HCV Ab), excluding a history of alcohol abuse; a B group (n = 25), who were seropositive for HBs Ag only; and a C group (n = 116), who were seropositive for HCV Ab only. We analyzed the features of tumor- and host-related factors and the outcome of the NBNC group.Results Hepatic inflammation and fibrosis were less severe in the NBNC group than in the other groups. There were no significant differences in tumor-related factors, except for higher serum levels of -fetoprotein in the NBNC group. Recurrence rates and disease-free survivals were comparable among the three groups. The NBNC group comprised a greater population with one or two recurrent hepatic lesions (P < 0.05), and indocyanine green retention rates and fibrosis scores were preserved after the initial hepatectomy. The NBNC group had higher resection rates for intrahepatic recurrences (75.0%) than the other groups (21.1% and 22.2% in groups B and C, respectively; P < 0.05 and P < 0.05). The survival rate after the initial hepatectomy or detection of the recurrent lesions was significantly better in the NBNC group (both 100% at 5 years) than those in groups B and C (P < 0.05).Conclusions NBNC patients maintained good liver function following the initial hepatectomy, and tended to have one or two recurrent lesions. These biological advantages provided NBNC patients more opportunities for repeat resection of intrahepatic recurrences, which may lead to a favorable outcome.     

Mechanism of free fatty acid-induced arrhythmias

This study was designed to shed light upon the mechanism of free fatty acid-induced arrhythmias, and to examine the effects of carnitine and its derivatives on such arrhythmias. Forty-two mongrel dogs were anesthetized and divided into six groups of seven animals each. The control group received only isotonic saline, while the lipid 1 ml/kg group and lipid 2 ml/kg group received lipid emulsions of 1 ml/kg and 2 ml/kg, respectively. The carnitine, acetylcarnitine or propionylcarnitine groups were given, respectively, 300 mg/kg of D,L-carnitine, 200 mg/kg of acetylcarnitine, and 100 mg/kg of D,L-propionylcarnitine, 10 min before they received 2 ml/kg infusions of lipid emulsion. The ventricular multiple response threshold (VMRT) of the animals was monitored over the course of time, and after the last measurement of VMRT, myocardial mitochondria were prepared, and their Ca⁺⁺-binding activities were measured. Concentrations of acyl-CoA and free L-carnitine in each mitochondrial sample were also measured. There was no significant difference in VMRT between the control group and the lipid 1 ml/kg group. In the lipid 2 ml/kg group, the VMRT was significantly lower than that of the control group, while it was found that premedication with carnitine or its derivatives significantly protected the VMRT against the effects induced by the infusion of 2 ml/kg of lipid emulsion. The mitochondria of the lipid 2 ml/kg group showed a markedly high accumulation of acyl-CoA, along with a concomitant decrease in Ca⁺⁺-binding activity. The 1 ml/kg infusion caused relatively small increase in acyl-CoA and had little effect on mitochondrial Ca⁺⁺-binding activity. The premedication with carnitine or its derivatives prevented the accumulation of acyl-CoA and preserved mitochondrial Ca⁺⁺-binding activity. These results suggest that free fatty acid-induced arrhythmias are closely related to the disturbance of mitochondrial Ca⁺⁺-binding activity induced by the accumulation of acyl-CoA, and that carnitine, especially propionylcarnitine, is effective in preserving the VMRT and mitochondrial Ca⁺⁺-binding activity despite subsequent 2 ml/kg lipid infusion.     

Resection of hepatic metastases of colorectal carcinoma: 20 years' experience

We analyzed the results and the prognostic factors influencing survival in 79 patients with metastases of colorectal carcinoma who underwent hepatectomy at our hospital in the 20-year period 1978—1998. The 5- and 10-year survival rates were 49% and 33%, respectively. Repeat hepatectomy was done 29 times in 24 patients with relapse of liver tumors. The 3- and 5-year survival rates after repeat hepatectomy were 58% and 14%, respectively. The distribution of and number of tumors in the liver, the disease-free interval from initial to second hepatectomy, and the presence of extrahepatic disease were significantly associated with survival (P < 0.01). Seven of 43 patients who underwent hilar node dissection had metastasis and 2 of them survived for more than 5 years. Repeat hepatectomy and hilar lymphadenectomy may be effective in prolonging the sur-vival of selected patients with hepatic metastasis. We also discuss prognostic factors after extensive surgery for hepatic metastases of colorectal carcinoma.     

Second cancer during long-term survival after resection of biliary tract carcinoma

Curative surgery for biliary tract malignancy has improved the prognosis of patients; however, during long-term follow up after extensive surgery, four of our patients (two with gallbladder carcinoma and two with bile duct carcinoma) developed a second primary cancer (one each in the duodenum, skin, descending colon, and lung). Regular examination of the upper gastrointestinal tract, colorectum, and lungs, and testing for tumor markers (carcinoembryonic antigen and CA19-9) were performed as follow-up studies. As a result, the second cancers were all found at a relatively early stage and all four patients are still alive 6–14 years after the initial operation. A review of the annual autopsy reports over the last 5 years in Japan showed that the incidence of second cancer was 14.8% in patients with gallbladder carcinoma and 13.5% in those with bile duct carcinoma. Furthermore, the rate of second gastric and colorectal carcinoma was significantly higher in patients with primary bile duct cancer than in those with primary gallbladder cancer. In conclusion, the incidence of a second cancer after resection of biliary tract malignancy is more than 10%, but this second cancer can be detected relatively easily and treated at an early stage during the course of regular long-term follow up for the first cancer.     

Double primary liver cancer (intrahepatic cholangiocarcinoma and hepatocellular carcinoma) in a patient with hepatitis C virus-related cirrhosis

We herein report a rare case of double primary liver cancer, consisting of intrahepatic cholangiocarcinoma (ICC) and hepatocellular carcinoma (HCC). A 67-year-old Japanese man with hepatitis C virus-related liver cirrhosis was diagnosed with multiple HCC in S7 and S8 of the liver. We performed a hepatic resection of S7 and S8. The liver tumors in S7 and S8 were pathologically diagnosed as HCC and ICC, respectively. Multiple recurrence of the HCC found 7 years after the surgery was successfully treated with transcatheter arterial chemoembolization. Subsequently, this patient has been doing well, without HCC recurrence. Double primary liver cancer is very rare, and only 21 resected cases have been reported, including that in our patient. We reviewed at all cases in the Japanese- and English-language literature to investigate the clinicopathological features. Our literature review revealed that the present patient is the longest survivor among patients who have undergone hepatectomy for double primary liver cancer.