New Pancreatic Duct-Invagination Anastomosis Using UltrasonicDissection for Nonfibrotic Pancreas with a Nondilated Duct

Nonfibrotic pancreases with a nondilated duct are susceptible to pancreatic fistula or leakage following pancreaticoduodenectomy. We developed a novel pancreatic duct-invagination anastomosis using an ultrasonic dissector and applied this technique to 14 consecutive pancreaticoduodenectomies and 1 segmental pancreatectomy for otherwise normal pancreases. With the aid of an ultrasonic dissector, even branch pancreatic ducts were skeletonized, ligated securely, and divided during pancreatic transection. Moreover, the main duct was exposed (> 1 cm) easily by ultrasonic dissection and a small-caliber pancreatic tube was inserted into the duct on the stump. Subsequently, pancreatic duct invagination could be easily done through a 10 G intravenous catheter passed through the gastrointestinal tract. The main duct was anchored to the adjacent serosa, but any pancreatic parenchymal sutures, possibly leading to internal laceration and/or parenchymal ischemia particularly in soft nonfibrotic pancreases, were avoidable during the procedures. All the anastomoses were done within 10 minutes. Only 1 patient (6.7%)developed pancreatic fistula, which resolved spontaneously in 21 days postoperatively. Neither anastomotic leakage nor remnant pancreatitis was seen in this series. Although a prospective, randomized study is needed, this technique may contribute to reduced morbidity after pancreaticoduodenectomy for a nonfibrotic pancreas with a nondilated main duct.     

A unique mechanism of giving way of the knee after tibial plateau fracture

This report describes a patient with a 31-month-old previously operated tibial plateau fracture who had frequent giving way of the involved knee. The symptoms and physical examination suggested a meniscus injury, which was finally ruled out by arthroscopy. Magnetic resonance imaging (MRI) in dynamic knee positions was then done, which showed that a bone ridge on the articular surface caused the symptoms by interfering with the lateral meniscus. The ridge was removed arthroscopically, and a satisfactory result was obtained.     

The efficiency of β2-agonist delivery through tracheal tubes with the metered-dose inhaler: an in vitro study

Purpose. To study the delivery efficiency of procaterol aerosols administered through the tracheal tube (ETT) with a metered-dose inhaler (MDI) during apnea. Methods. First, in a normal room air environment (at ambient temperatures of 24° to 26°C), we measured the amount of aerosol delivered through the ETT by comparing the weight of a 2-l bottle before and after firing the MDI directly into the 15-mm adapter of the ETT. The distal half of the ETT was inserted in the bottle. This procedure was repeated using five different ETTs with an internal diameter of 4–8.5 mm. The delivery efficiency was obtained by dividing the amount of aerosol delivered through the ETT by the total aerosol output per MDI puff. Next, we investigated whether the connector attached to the 15-mm ETT adapter could reduce the delivery, by repeating the same procedure with 4-mm and 5-mm ETTs. Finally, we compared the efficiencies of aerosol delivery through the 5-mm ETT and the 7.5-mm ETT in a normal room air environment with results obtained under a humidified condition (100% humid air at 37°C). Results. The percentages of aerosol delivered through the ETTs in a normal room air environment were 40%–60%, except for the 4-mm ETT, for which the percentage was 32.7% ± 6.6% (P < 0.05 vs that with the 5-mm ETT or the 6-mm ETT). A connector attached to the 15-mm ETT adapter significantly decreased the delivery efficiencies (19.0% ± 5.8% vs 32.7% ± 6.6% with the 4-mm ETT, 24.6% ± 11.8% vs 51.7% ± 10.8% in the 5-mm ETT) when compared with those without a connector. The delivery efficiencies under the humidified condition in the 5-mm ETT and the 7.5-mm ETT were 65.5% (P < 0.05) and 89.8% of those in the normal room air environment, respectively. Conclusion. The efficiency of delivery of procaterol aerosol through the ETTs was unexpectedly high (approximately half of the total aerosol output per MDI puff in the 5-mm to 8.5-mm ETTs, and one third of the total aerosol output per MDI puff in the 4-mm ETT). A connector attached to the 15-mm ETT adapter noticeably decreased the delivery efficiency. In the smaller-sized ETT, delivery efficiency was significantly lower under the humidified condition than in the normal room air environment. Received: September 28, 2001 / Accepted: June 24, 2002 Address correspondence to: T. Takaya     

Solitary Intraperitoneal Recurrence of α-Fetoprotein-Producing Gastric Carcinoma: Report of a Case

Abstact A solitary recurrence of gastric carcinoma in the peritoneal cavity is extremely rare. We herein present a case of solitary intraperitoneal recurrence in a patient with α-fetoprotein (AFP)-producing gastric carcinoma. As far as we can determine, this is the first report of such a form of recurrence in a patient with gastric carcinoma who underwent a successful resection. A review of our eight patients who had AFP-producing gastric carcinoma showed a frequent association with hepatic metastasis and a poor prognosis as has been reported previously. Our patient received intra-arterial chemotherapy with low-dose cisplatin and 5-fluorouracil to prevent hepatic recurrence, but eventually developed multiple hepatic metastases after ceasing this therapy. Therefore, adjuvant intra-arterial chemotherapy may have altered the site of first recurrence in this patient. Received: June 6, 2001 / Accepted: November 20, 2001     

Bacteria isolated from surgical infections and their susceptibilities to antimicrobial agents--special references to bacteria isolated between April 2000 and March 2001

Tendency of isolated bacteria from infections in general surgery and their antimicrobial susceptibilities during the period from April 2000 to March 2001 were investigated in a multicenter study in Japan, and the following results were obtained. The number of cases investigated as objectives was 234 for one year. A total of 388 strains (136 strains from primary infections and 252 strains from postoperative infections) were isolated from 165 cases (70.5% of total cases). In primary infections, anaerobic Gram-positive bacteria were predominant, while from postoperative infections, aerobic Gram-positive bacteria were predominant. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus faecalis was the highest, followed by that of Staphylococcus aureus from postoperative infections. Among anaerobic Gram-positive bacteria, the isolation rate of Peptostreptococcus spp. was the highest from both types of infections. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae and Pseudomonas aeruginosa in this order, and from postoperative infections, P. aeruginosa was the most predominantly isolated, followed by Enterobacter spp. and Klebsiella spp. Among anaerobic Gram-negative bacteria, the isolation rate of Bacteroides fragilis group was the highest from both types of infections. There was no vancomycin-resistant S. aureus nor Enterococcus spp. Among anaerobic bacteria, there were many resistant strains against penicillins and cephems with MICs higher than 100 micrograms/ml, and the same trend was observed among other Bacteroides spp. and Prevotella spp.     

Incidence and clinical course of major depression in patients with chronic hepatitis type C undergoing interferon-alpha therapy: a prospective study

This study examined the incidence, clinical course and its risk factors for major depression in patients with chronic hepatitis type C undergoing interferon-alpha therapy. Ninety-nine subjects underwent the psychiatric interviews for diagnosis of major depressive episode according to the DSM-IV criteria before the start of interferon therapy, and once every 4 weeks during both the 24-week treatment period and 12 weeks after the end of therapy. Depressive symptoms were also evaluated using the Hamilton Rating Scale for Depression. Major depression occurred during interferon therapy in 23 patients (23.2%). In 73.9% of them depression occurred within 8 weeks after the start of therapy. Twenty-two patients with depression completed the therapy and 59.1% of them achieved remission by the end of therapy with a mean duration of 11.6 weeks. Although the other 40.9% were not in remission at the end of therapy, they achieved remission within 12 weeks thereafter. The only risk factor for depression was advanced age. Depression occurs frequently among patients with hepatitis type C undergoing interferon-alpha therapy. Such patients require careful observation, and psychiatrists should be sufficiently aware of this significant psychiatric complication of interferon therapy.     

Subtotal nephrectomy stimulates cyclooxygenase 2 expression and prostacyclin synthesis in the rat remnant kidney

BACKGROUND: Recently, two isoforms of cyclooxygenase (COX) have been identified, a constitutive form (COX-1) and a mitogen-inducible form (COX-2). Several studies have suggested that COX is activated in renal insufficiency, but little is known about the relationship between progression of renal insufficiency and the COX isoforms. METHODS: Five-sixths-nephrectomized (NX) rats were used. 4, 8, and 12 weeks after nephrectomy, the renal cortical prostaglandin contents and the expression levels of the two isoforms of COX were determined by enzyme immunoassay and Western-blotting, respectively. The localization of COX was examined by immunohistochemistry. RESULTS: Renal cortical prostacyclin (PGI2) and COX-2 were significantly upregulated 8 and 12 weeks after NX, while COX-1 remained at the basal level. There was a high correlation between COX-2 and creatinine clearance (r = -0.845). There was also a high correlation between COX-2 and PGI2 (r = 0.816). Immunohistochemistry revealed the expression of COX-2 to be enhanced in the macula densa in NX rats. CONCLUSIONS: Renal cortical COX-2 and prostacyclin were upregulated corresponding to the progression of renal insufficiency in NX rats. These results suggest enhancement of COX-2 expression in the macula densa, perhaps stimulated by a decrease in renal blood flow which upregulates PGI2 synthesis to protect the kidney from ischemia in renal insufficiency.     

Selection of pancreaticojejunostomy techniques according to pancreatic texture and duct size

HYPOTHESIS: Selection of proper pancreaticojejunostomy techniques according to pancreatic texture and the main duct size reduces the pancreatic fistula rate. DESIGN AND PATIENTS: Data from 50 consecutive patients undergoing pancreatoduodenectomy with 3 different anastomotic techniques prospectively used according to pancreatic texture and the main duct size were analyzed. Duct-invagination anastomosis was selected for pancreata with a small duct (n = 34 [29 with a soft texture and 5 with a hard texture]). Stitches between the stump parenchyma and the jejunal seromuscular layer were added to this anastomosis procedure only for the hard pancreata. Pancreata with a large duct were reconstructed with a conventional duct-to-mucosa anastomosis (n = 16). SETTING: A university hospital department of digestive surgery. RESULTS: The morbidity was 40% (20 of 50 patients) in this series. Four patients (8%) with a soft pancreas and a small duct developed a pancreatic stump leak after duct-invagination anastomosis, but all of them were removed without sequelae. No pancreatic anastomotic leak was seen in this series, which resulted in no mortality, no remnant pancreatectomy, and only 1 relaparotomy in the consecutive 50 patients. CONCLUSION: The proper selection of pancreatic reconstruction techniques according to our criteria may reduce the pancreatic fistula rate, eliminate risky pancreatic anastomotic leaks, and result in excellent outcomes for those undergoing pancreatoduodenectomy.     

Extracellular Bad fused to toxin transport domains induces apoptosis

Bad, a proapoptotic member of the Bcl-2 family, is inactivated by phosphorylation, and this loss of activity may contribute to the malignancy of certain types of tumors such as glioblastoma and prostate cancer. To determine whether extracellular Bad can be delivered into cells via cell surface receptor binding and induce apoptosis, we genetically fused the mouse Bad gene to the gene for the translocation and receptor-binding domains of diphtheria toxin (DTTR). The purified Bad (wild-type)-DTTR protein showed cytotoxicity to human glioma cells in a dose-dependent manner. Bad phosphorylation sites at codons 112 and 136 were mutated from serine to alanine to prevent Bad inactivation by kinases and to increase the toxicity of Bad. The Bad (S112A S136A)-DTTR protein was at least 5 times more toxic than Bad (wild-type)-DTTR with an IC(50) of 5 x 10(-8) M. The Bad (S112A S136A)-DTTR protein altered the subcellular distribution of Bcl-X(L), indicating that it enters the cell cytoplasm and binds Bcl-X(L). Bad (S112D S136A)-DTTR, mutated to mimic phosphorylation of Bad, showed lower toxicity than either Bad (wild-type)-DTTR or Bad (S112A S136A)-DTTR, additionally indicating that Bad-DTTR must bind Bcl-X(L) to stimulate apoptosis. We conclude that extracellular Bad can be delivered into cells via the transport domain of a bacterial toxin and may be used to induce apoptosis.     

Comparison of the morphological changes of restenosis after the implantation of various types of stents in a swine model

BACKGROUND: Stent design causes the differences of restenosis rate, but the morphological differences after the various types of stent implantation have not been clarified. DESIGN: Seven types of stents were implanted in pig coronary arteries to clarify how the mechanism of restenosis differs with coil stents and tube stents. METHODS: The left anterior descending coronary arteries (LADs) of pigs were injured using coronary angioplasty balloons (diameter: 3.0 mm; length: 20 mm; balloon/artery ratio: 1 : 2). Fourteen days after the injury, four types of coil stents (Cordis, Wiktor, GR-I, and GR-II) and three types of tube stents (Palmaz-Schatz, gfx, and Multilink) were implanted, and the LADs were extracted 28 days after the implantation. RESULTS: The proliferated neointima was eccentric in the coil stents and concentric in the tube stents. Although there was no significant difference in the area of neointima, the area of the lumen was significantly larger in the tube stents than in the coil stents ( < 0.01) because of the larger area of stent. Cells positive for anti-proliferating cell nuclear antigen antibody were mainly observed around the stent struts, and most of these cells were also positive for either anti-macrophage or anti-smooth muscle actin antibodies. CONCLUSIONS: Compared to the coil stents, the tube stents induce less negative remodelling including stent recoil, resulting in a wider luminal area. In order to prevent restenosis, it is crucial to implant a stent that will cause less negative remodelling.