Intraductal Oncocytic Papillary Neoplasm of the Pancreas with Celiac Artery Compression Syndrome and a Jejunal Artery Aneurysm: Report of a Case

A 79-year-old woman presented with epigastralgia, and computed tomography showed a 3-cm multiloculated mass with a mural nodule in the head of the pancreas. Arteriography showed stenosis of the celiac artery and a saccular aneurysm, arising from the first jejunal artery. We made a preoperative diagnosis of intraductal papillary adenocarcinoma of the pancreatic head and performed a laparotomy. Transection of the median arcuate ligament failed to restore adequate hepatic blood flow, necessitating construction of celiac vascularization, achieved by a gastroduodenal to jejunal artery anastomosis. After ligation of the jejunal artery aneurysm, we performed a pylorus-preserving pancreaticoduodenectomy. Microscopically, the tumor had papillary intracystic growth, and was lined by plump cells with abundant eosinophilic cytoplasm, consistent with a diagnosis of intraductal oncocytic papillary neoplasm. We discuss this recently recognized entity of papillary neoplasm of the pancreas, and the importance of managing hepatic blood flow during pancreaticoduodenectomy in celiac artery compression syndrome.     

Autologous bone marrow stromal cell transplantation for repair of full-thickness articular cartilage defects in human patellae: two case reports

This study assessed the effectiveness of autologous bone marrow stromal cell transplantation for the repair of full-thickness articular cartilage defects in the patellae of a 26-year-old female and a 44-year-old male. These two patients presented in our clinic because their knee pain prevented them from walking normally. After thorough examination, we concluded that the knee pain was due to the injured articular cartilage and decided to repair the defect with bone marrow stromal cell transplantation. Three weeks before transplantation, bone marrow was aspirated from the iliac crest of each patient. After erythrocytes had been removed by use of dextran, the remaining nucleated cells were placed in culture. When the attached cells reached subconfluence, they were passaged to expand in culture. Adherent cells were subsequently collected, embedded in a collagen gel, transplanted into the articular cartilage defect in the patellae, and covered with autologous periosteum. Six months after transplantation, clinical symptoms (pain and walking ability) had improved significantly and the improvement has remained in effect (5 years and 9 months posttransplantation in one case, and 4 years in the other), and both patients have been satisfied with the outcome. As early as 2 months after transplantation, the defects were covered with tissue that showed slight metachromatic staining. Two years after the first and 1 year after the second transplantation, arthroscopy was performed and the defects were repaired with fibrocartilage. Results indicate autologous bone marrow stromal cell transplantation is an effective approach in promoting the repair of articular cartilage defects.     

Middle mesenteric artery: Angiographic and three-dimensional computed tomography findings

The middle mesenteric artery, also known as the third mesenteric artery, is a very rare anomaly. Several anatomical variations of middle mesenteric artery have been reported; in these reports, the right colic artery and/or middle colic artery often originate directly from the aorta. Here, we report a middle mesenteric artery in which the middle colic artery originated directly from the abdominal aorta. We also provide three-dimensional computed tomography and angiography findings and discuss anatomical and embryological considerations.     

Silver-catalyzed three-component reaction of uracils,arylboronic acids,and selenium: synthesis of 5-arylselanyluracils

Herein, we describe a simple and general multi-component synthesis of 5-arylselanyluracils by the regioselective C–H selenation of uracils. Reactions of uracils with arylboronic acid and Se powder in the presence of AgNO₃ (10 mol%) at 120 °C under aerobic conditions afforded various 5-arylselanyluracils. The source of the introduced selanyl group was prepared from a commercially available arylboronic acid and Se powder in the reaction system, thereby ensuring a simple and efficient protocol. This reaction represents the first example of the synthesis of a 5-arylselanyluracil in a multi-component system.

A simple and general multicomponent synthesis of 5-arylselanyluracils by regioselective C–H selenation of uracils is described.     

Lobectomy by video-assisted thoracic surgery for lung cancer patients aged 80 years or more.

To clarify the usefulness of video-assisted lobectomy for lung cancer patient aged 80 years old or more, a retrospective study was conducted to evaluate the clinical outcome. Between 1982 and 2001, 914 patients underwent surgery for primary lung cancer at the Nippon Medical School Hospital. Among them, 32 patients underwent lobectomy, including 17 with a mean age of 82 years (range, 80 to 91 years) who underwent video-assisted lobectomy and 15 with a mean age of 82 years (range, 80 to 86 years) who underwent lobectomy by standard thoracotomy. Of these 32 patients, clinical outcome was evaluated retrospectively. Mortality was 4 (12.5%) of 32 patients consisting of 3 (20%) of 15 who underwent lobectomy by standard thoracotomy and 1 (5.9%) of 17 who underwent video-assisted lobectomy. Single variate analyses revealed that the presence of preoperative cardiopulmonary disease, 0.6 L or more of predicted postoperative forced expiratory volume in one second/m(2), 700 ml or more of blood loss, five hours or more of duration of operation and two or more of postoperative complications were considered as risk factors regarding mortality within three months postoperation. Among the patients who underwent lobectomy with mediastinal lymph node dissection, the 5-year survival rate at stage I (IA+IB) was 55.6% for patients who underwent video-assisted lobectomy and 0% for patients who underwent lobectomy by standard thoracotomy (IA=2, IB=2). Video-assisted lobectomy for lung cancer patients aged 80 years or more is considered to offer an acceptable clinical outcome. However, further observation on prognosis is necessary.     

A Simple Technique for Performing Laparoscopic Purse-String Suturing During Circular Stapling Anastomosis

An esophagojejunostomy using a circular stapler requires the fixing of an anvil at the esophageal stump. When this placement procedure is laparoscopically performed, purse-string suturing is difficult, and there is a risk of loosening when a conventional needle driver is used. We herein present a simple but effective technique for performing laparoscopic purse-string suturing of the esophageal stump using a semiautomatic suturing device called the Endostitch. Gastrointestinal anvil placement was laparoscopically performed for 10 patients who underwent an esophagojejunostomy following a total gastrectomy. After the lumen of the esophagus was expanded using bowel forceps, the Endostitch was used to place approximately 12 encircling purse-string sutures. An anvil was positioned with support of the esophageal wall at three points with forceps. The Endostitch was used for the ligation with a sufficient degree of tension applied by extracorporeally pulling the sutures through the abdominal wall. The time for placement of the anvil averaged approximately 8 min. The ring formation following anastomosis was favorable in all patients. As a result, we consider our technique to be simple but very effective.     

Endovascular interventions for hepatic artery complications immediately after pediatric liver transplantation

Hepatic artery complications after living donor liver transplantation (LDLT) can directly affect both graft and recipient outcomes. For this reason, early diagnosis and treatment are essential. In the past, relaparotomy was generally employed to treat them. Following recent advances in interventional radiology, favorable outcomes have been reported with endovascular treatment. However, there is ongoing discussion regarding the best and safe time for definitive endovascular interventions. We herein report a retrospective analysis for six children with early hepatic artery complication after pediatric LDLT who underwent endovascular treatment as primary therapy at our institution. We evaluate the usefulness of endovascular treatment for hepatic artery complication and its optimal timing. The mean patient age was 11.9 months and mean body weight at LDLT was 6.7 kg. The mean duration between the transplantation and first endovascular treatment was 5.3 days. Five of the six patients were technically successful treated by only endovascular treatment. Of these five patients, two developed biliary complications. Endovascular procedures were performed 10 times in six patients without any complications and nine of the 10 procedures were successful. By selecting optimal devices, our findings suggest that endovascular treatment can be feasible and safe in the earliest time period after pediatric LDLT.     

Is pancreaticogastrostomy safer than pancreaticojejunostomy?

Background/Purpose Failure of a pancreatic–enteric anastomosis very frequently leads to morbidity and mortality after pancreaticoduodenectomy. Pancreaticojejunostomy or pancreaticogastrostomy is often used after pancreaticoduodenectomy. The many reports on pancreaticogastrostomy support the low rates of anastomotic leakage and mortality compared with pancreaticojejunostomy. Methods Between January 1995 and December 2004, 155 pancreaticojejunostomies and 58 pancreaticogastrostomies were performed after pancreatic resection in the Second Department of Surgery of Nagoya University Hospital. Postoperative morbidity and mortality were analyzed. Results The incidence of pancreatic fistula was similar for the pancreaticojejunostomy (12.2%) and pancreaticogastrostomy (20.7%) groups and the mortality rate was 0% in both groups. Conclusions This restrospective clinical study suggested no significant difference in the incidence rate of pancreatic fistula and mortality between pancreaticojejunostomy and pancreaticogastrostomy.     

Usefulness of Preoperative Plasma Fibrinogen Versus Other Prognostic Markers for Predicting Gastric Cancer Recurrence

Background

Hypercoagulation is associated with tumor progression and metastasis in various types of malignancy. We compared the prognostic value of preoperative plasma fibrinogen level with those of other prognostic markers in patients with gastric cancer and assessed whether fibrinogen level was an independent prognostic indicator.

Methods

We collected preoperative data from 609 consecutive patients with gastric cancer who underwent curative gastrectomy. A receiver operating curve (ROC) was used to compare the sensitivity and specificity of carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), C-reactive protein (CRP), platelet count, platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), and fibrinogen level in predicting recurrence. Recurrence-free survival (RFS) and overall survival (OS) were compared between the normal and high fibrinogen groups.

Results

In the ROC analysis, the area under the curve (AUC) was 0.534 for CEA, 0.552 for CA19-9, 0.587 for CRP, 0.565 for platelet count, 0.567 for PLR, 0.522 for NLR, and 0.692 for fibrinogen. Plasma fibrinogen level increased with tumor stage. The high fibrinogen (≥350 mg/dl) group had significantly worse RFS (p < 0.001) and OS (p < 0.001) than the normal fibrinogen (<350 mg/dl) group. Cox multivariate analysis of RFS revealed that fibrinogen level was an independent prognostic factor (p < 0.001) in addition to sex, pT stage, and pN stage.

Conclusions

Preoperative plasma fibrinogen level had the highest predictive value for recurrence among seven known prognostic markers. Since fibrinogen level is an independent factor for RFS, it would be useful for predicting prognosis after gastric cancer surgery.

     

Modified Blumgart Anastomosis for Pancreaticojejunostomy: Technical Improvement in Matched Historical Control Study

Background

Postoperative pancreatic fistula (POPF) is the main cause of fatal complications after pancreatoduodenectomy. There is still no universally accepted technique for pancreaticoenterostomy, especially in patients with soft pancreas.

Methods

Between July 2008 and June 2013, 240 patients who underwent pancreatoduodenectomy were enrolled in this single-institution matched historical control study. To approximate the pancreatic parenchyma to the jejunal seromuscular layer, 120 patients underwent anastomosis using the Kakita method (three or four interrupted penetrating sutures) and 120 underwent anastomosis using the modified Blumgart anastomosis (m-BA) method (one to three transpancreatic/jejunal seromuscular sutures to completely cover the pancreatic stump with jejunal serosa).

Results

The rate of clinically relevant POPF formation was significantly lower in the m-BA group than that in the Kakita group (2.5 vs 36 %; p?<?0.001). The duration of drain placement and the length of postoperative hospital stay were significantly shorter in the m-BA group. Multivariate analysis showed that m-BA was an independent predictor of non-formation of POPF (hazard ratio, 0.02; 95 % confidence interval, 0.01–0.08; p?<?0.001).

Conclusion

The m-BA method is safe and simple and improves postoperative outcomes. We suggest that the m-BA is suitable for use as a standard method of pancreaticojejunostomy after pancreatoduodenectomy.