The clinical role of critical pathway implementation for pancreaticoduodenectomy in 179 patients

Background/purpose

In June 2004, a critical pathway for patients undergoing pancreaticoduodenectomy (PD) was introduced. The objective of this study was to determine the clinical value of critical pathway implementation.

Methods

256 consecutive patients who underwent PD between 2000 and 2010 were divided into 4 groups by date of operation as follows; group A (n = 77), the pre-pathway group; group B (n = 51), the CP implementation group who were managed according to departmental guidelines; group C (n = 78), the group who had no stenting in the reconstruction of PD; and group D (n = 50), the group who had reinforcement of the pancreaticojejunostomy. The success rates of clinical outcomes and post-operative morbidity were compared between each group, year by year and every 50 patients.

Results

The success rates of clinical outcomes, including the timings of nasogastric tube removal, discontinuation of prophylactic anti-microbial agent, drain removal, starting oral intake, and patient discharge, were significantly improved in group B relative to group A, and in group C relative to group B. There were no significant differences in mortality and morbidity between any of the groups. All clinical outcomes reached a plateau at 2–3 years or 100–150 patients’ operations after critical pathway implementation.

Conclusions

Long-term use of a critical pathway is associated with improved clinical outcomes. A certain period of time or volume of patients is needed for this improvement in clinical outcomes to reach a plateau, which indicates achieving standardization of peri-operative management.     

Duct of Luschka diagnosed by sonography in a patient with bile duct carcinoma and intrahepatic bile duct dilatation

The bile duct of Luschka (BDL) is an anatomic anomaly that is an important cause of bile leakage after bile duct surgery. We report a case of bile duct carcinoma with dilated BDL that was diagnosed by ultrasonography (US). An 83‐year‐old man presented with an obstructive jaundice. US on admission revealed the presence of a solid hypoechoic mass in the bile duct at the hepatic duct confluence and a branch of the bile duct, about 2–4 mm in diameter, distinct from the dilated right anterior hepatic duct slightly upstream of the tumor. This branch had a spiral structure, extended along the gallbladder bed on the surface of segment 5 (S5) of the liver, and emanated small branches that entered the hepatic parenchyma. There has been no previous report of delineation of BDL by preoperative US. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound 41 :558–562, 2013.     

Combined rupture of trachea and esophagus following blunt trauma — a case report —

A 49-year-old man was involved in a motor vehicle crash and was admitted to a local hospital. The following day, he was transferred to our hospital because of worsening dyspnea. Initial examination revealed no subcutaneous emphysema, and chest computed tomography (CT) demonstrated no mediastinal air. A left thoracentesis tube was placed for pneumothorax, which reduced the patient’s respiratory distress. He had a persistent, productive cough, which worsened when he drank water. A repeat chest CT on the fifth hospital day revealed a tracheo-esophageal fistula. Bronchoscopy and esophagoscopy confirmed the diagnosis. He underwent repair of the trachea and esophagus. The ruptured membraneous portion of the trachea was closed with interrupted sutures and covered with pedicled pericardial flap. The perforated anterior esophageal wall was sutured in layers and reinforced with a fifth intercostal muscle flap. A gastrostomy tuve was placed for feeding access. Within 6 weeks, the patient recovered completely.     

Cytosolic and membrane-bound nitric oxide synthase.

Cytotoxic activated macrophages were sonicated and centrifuged. The activity of nitric oxide (NO) synthase was present in the supernatant and independent of Ca2+. The pellets were washed three times and treated with buffer containing 0.1% Triton X-100 or buffer alone, followed by centrifugation. The supernatant containing Triton X-100 showed NO synthase activity that was dependent on Ca2+, whereas the supernatant without the detergent had little activity. These data suggest that there are two forms of NO synthase: cytosolic and membrane-bound enzymes.     

High-dose intravenous immunoglobulin in the treatment of sensory ataxic neuropathy with Sj?gren's syndrome: a case report]

We report herein a case of sensory ataxic neuropathy with Sj?gren's syndrome (SS-SAN) who became dramatically improved in response to high-dose intravenous immunoglobulin treatment (IVIg). An 81-year-old man began to feel numbness in his hands and feet in August 2002. Because he became unsteady and could not do skillfull movement, he was admitted to our hospital in May 2003. On neurological examination, all tendon reflexes were absent. His vibratory and position senses were severely impaired to knees and elbows. Touch, temperature, and pinprick sensations were mildly disturbed in a glove-stocking distribution. Coordination was clumsy in all limbs because of sensory loss. He had gait ataxia with Romberg sign. Nerve conduction study revealed that sensory nerve action potentials were absent. He was diagnosed as having SS-SAN because Schirmer test, Saxon test and both SS-A and SS-B antibodies were positive. Thereafter, Mg, 400 mg/kg daily for 5 days, was administered. His sensory impairment began to improve 2 days after Mg. Subsequently, he could walk steadily without ataxia. It is considered that IVIg may be an effective treatment for SS-SAN.     

Effect of irradiation on lung metastasis of VX2 carcinoma in maxillary sinus of rabbit

Summary Effects of local single irradiation on lung metastasis of VX2 carcinoma transplanted in maxillary sinus of rabbits were evaluated. When an inadequate irradiation for complete regression was given, the rate of pulmonary metastases in irradiated groups was remarkably increased compared with non-irradiated one, although tumor growths in irradiated ones were apt to be inhibited corresponding to the given dose. Three parameters detected in the study related to general conditions were not so significantly different among the groups although those in irradiated groups were apt to be worse than those in control. Histologically most remarkable difference between in control and irradiated groups was stromal respose. However, on the question of whether stromal response could react as a diffensive or promotive mechanisms against tumor metastases, further studies would be needed including analysis of infiltrative cells.