Postpancreatoduodenectomy Hemorrhage Treated by Combined Transcatheter Arterial Embolization and Superior Mesenteric Artery to Iliac Artery Bypass: Report of a Case

Postpancreatectomy hemorrhage is a potentially life-threatening complication. We report herein our experience with a 65-year-old man with locally advanced pancreatic adenocarcinoma who underwent pancreatoduodenectomy with lymphadenectomy following neoadjuvant chemoradiotherapy. On postoperative day 45, he developed massive hematemesis. Angiography revealed active bleeding from the common hepatic artery, and transcatheter coil embolization of that vessel was successfully performed. On postoperative day 64, he again developed massive hematemesis. Angiography revealed active bleeding from the proximal superior mesenteric artery. Immediately after coil embolization of that vessel, bypass grafting between the superior mesenteric artery and the right common iliac artery was performed, using a greater saphenous vein graft. The combination of embolization and bypass grafting is an option for treatment of bleeding from the superior mesenteric artery in an emergent situation.Key words: Superior mesenteric artery, Bleeding, Bypass, Pancreatoduodenectomy, Postpancreatectomy hemorrhagePostpancreatectomy hemorrhage (PPH) is a rare but life-threatening complication, often associated with the presence of a pancreatic fistula or intraabdominal abscess.¹ The mortality associated with arterial bleeding after pancreatoduodenectomy is reportedly between 14.3% and 30.7%.^2–6 With recent advances in interventional radiology techniques, transcatheter arterial embolization (TAE) has become an alternative to surgical treatment.^3,5,7,8 However, it may be difficult to treat these patients with interventional radiology techniques alone, given their often unstable condition. In addition, the inappropriate use of TAE for arterial bleeding, especially after pancreatoduodenectomy, can lead to end-organ infarction and subsequent infection. We report herein our experience with a patient who had bleeding from the superior mesenteric artery (SMA) after pancreatoduodenectomy. This patient was successfully treated using SMA coil embolization followed by creation of an SMA-iliac artery bypass using a greater saphenous vein graft.     

Frequency of provoked coronary vasospasm in patients undergoing coronary arteriography with spasm provocation test of acetylcholine

This study examines the incidence of spasm by intracoronary injection of acetylcholine in Japanese patients who underwent coronary angiography. The subjects were 685 consecutive patients (477 men, mean age 63.2 +/- 7.5 years) who were studied with an acetylcholine test. Acetylcholine was injected in incremental doses of 20, 50, and 80 microg into the right coronary artery and 20, 50, and 100 microg into the left coronary artery. Spasm was defined as total or subtotal occlusion. Coronary vasospasm was determined in 221 patients (32.3%). Spasm occurred often during effort and rest in patients with angina (25 of 51, 49.0%), exertional angina (25 of 74, 33.8%), recent myocardial infarction (30 of 80, 37.5%), healed myocardial infarction (14 of 37, 37.8%), and especially in patients with rest angina (83 of 124, 66.9%), whereas spasm was relatively uncommon in patients with nonischemic heart disease (23 of 252, 9.1%). Spasm was superimposed on significant atherosclerotic lesions in 35.9% of patients as well as on nonfixed atherosclerotic lesions in 30.8% of patients. We conclude that >9% of Japanese patients may have coronary vasospasm with intracoronary injection of acetylcholine and recommend the provocation test for evaluating coronary vasospasm if coronary angiography is undertaken.     

Carboxylic monolayer formation for observation of intracellular structures in HeLa cells with direct electron beam excitation-assisted fluorescence microscopy

Intracellular structures of HeLa cells are observed using a direct electron beam excitation-assisted fluorescence (D-EXA) microscope. In this microscope, a silicon nitride membrane is used as a culture plate, which typically has a low biocompatibility between the sample and the silicon nitride surface to prevent the HeLa cells from adhering strongly to the surface. In this work, the surface of silicon nitride is modified to allow strong cell attachment, which enables high-resolution observation of intracellular structures and an increased signal-to-noise ratio. In addition, the penetration depth of the electron beam is evaluated using Monte Carlo simulations. We can conclude from the results of the observations and simulations that the surface modification technique is promising for the observation of intracellular structures using the D-EXA microscope.OCIS codes: (170.0170) Medical optics and biotechnology, (170.0180) Microscopy     

Monocyte/Macrophage-Specific Marker CD163+ Histiocytic Sarcoma: Case Report with Clinical, Morphologic, Immunohistochemical, and Molecular Genetic Studies

We report a case of a very rare disorder, histiocytic sarcoma, from a review of our autopsy cases. The neoplastic cells that proliferated in organs throughout the body were large cells containing eosinophilic cytoplasm and pleomorphic nuclei with prominent nucleoli. In the bone marrow, erythrophagocytosis by neoplastic cells was observed. The neoplastic cells were positive not only for lysozymes and CD68 (KP-1, PG-M1, and Ki-M1P) but also for a monocyte/macrophage-specific marker, CD163. In contrast, the results of tests for markers of myeloid cells, lymphoid cells, and epithelial cells were all negative. In a polymerase chain reaction study of paraffin-embedded tissues, analyses for the rearrangement of immunoglobulin heavy chain and T-cell receptor-γ genes were negative. The current World Health Organization diagnostic criteria for histiocytic sarcoma regard immunohistochemical investigation as crucial. In this regard, the highly specific positivity for CD163 in this patient indicates that immunohistochemical staining of CD163 is very useful for the diagnosis of histiocytic sarcoma.     

Isolated ACTH deficiency with Graves' disease: a case report

A 60-year-old man was hospitalized with complaints of general malaise and weight loss. On admission, ACTH and cortisol levels were low, and thyroid function tests revealed hyperthyroidism. These findings and further examination led to a diagnosis of isolated ACTH deficiency (IAD) with Graves' disease. It is known that IAD is frequently associated with thyroid disease, but its association with Graves' disease is rare. The present case is worth noting, because some reports indicate that aggravation of associated Graves' disease may concomitantly aggravate adrenal insufficiency in patients with IAD.