Falciform ligament in pancreatoduodenectomy for protection of skeletonized and divided vessels

Background/purpose

Pancreatic fistula, which is one of the main causes of late postpancreatectomy hemorrhage (PPH), is a common complication of pancreatoduodenectomy (PD). It may erode the anastomosis site and vascular wall in its vicinity, resulting in pseudoaneurysm formation and/or the rupture of major vessels. To protect the vessels near the area for pancreaticojejunostomy from potential pancreatic fistula, we have adopted a surgical option by which such vessels are separated from the pancreaticojejunostomy using a pedicled falciform ligament. We reviewed 36 patients who underwent PD that included this option.

Methods

After the PD was completed (before reconstructions), the pedicled falciform ligament was spread widely on the major vessels exposed during resection, and was fixed to the surrounding retroperitoneal connective tissue. These procedures enabled the complete separation of these vessels from the pancreaticojejunostomy.

Results

The mobilization and placement of the falciform ligament in the space between the pancreaticojejunostomy and the major vessels were successfully carried out without any complications. Although ten (28%) patients developed pancreatic fistula and three (8%) developed intraabdominal infection, none of the patients developed late PPH.

Conclusions

The present surgical option is technically simple and easy, and may be an effective prophylactic measure against late PPH following PD.     

Differential diagnosis of dysplasia-associated lesion or mass and coincidental adenoma in ulcerative colitis

PURPOSE: This study was undertaken to investigate factors that influenced differential diagnosis of dysplasia-associated lesion or mass and coincidental adenoma in patients with ulcerative colitis. METHODS: Among 346 patients with ulcerative colitis who underwent colonoscopy between 1979 and 1995, 27 patients had macroscopic neoplastic lesions and were divided into two groups: those with dysplasia-associated lesion or mass (16 patients) and those with adenoma (11 patients), each being categorized by the presence and absence of dysplasia in the flat mucosa adjacent to the elevated lesions, respectively. RESULTS: Thirteen of 27 patients had dysplasia-associated lesion or mass detected by colonoscopic biopsy; 10 of these patients underwent colectomy, and all had dysplasia-associated lesion or mass in the colectomy specimens. Two patients whose biopsy findings were adenoma had an unsuspected dysplasia-associated lesion or mass in the operative specimens. In the remaining 12 patients, the macroscopic lesions were excised during colonoscopy because of clinical and colonoscopic evidence of adenoma. One of them was proved to have dysplasia-associated lesion or mass, and the other 11 were confirmed as having adenoma in the polypectomy specimens. Patients with dysplasia-associated lesion or mass were significantly younger (P<0.05), had longer duration of ulcerative colitis (P<0.01), and had more extensive disease (P<0.005) than those with adenoma. The colonoscopic appearance was plaque-like in 13, sessile in 13, and pedunculated in 2 of the 28 lesions with dysplasia-associated lesion or mass, whereas it was plaque-like in only 1 and sessile or pedunculated in 15 of the 16 lesions with adenoma (P<0.001). The mean size of the lesions that were considered to be dysplasia-associated lesions or mass and adenoma was 1.8 and 0.5 cm, respectively (P<0.0001). CONCLUSIONS: Colonoscopic biopsy for detection of dysplasia in the flat mucosa adjacent to macroscopic neoplastic lesions is an appropriate preoperative approach to distinguish dysplasia-associated lesions or mass from adenomas in patients with ulcerative colitis. The statistically significant variables that influenced the differential diagnosis were age, duration of disease, extent, tumor size, and tumor colonoscopic appearance.Read in part at the meeting of The Japan Society of Coloproctology, Tokyo, Japan, October 20 to 21, 1995.     

Clinicopathological features of serrated lesions of the colorectum

We reviewed 428 subjects with colorectal serrated lesions resected endoscopically or surgically at our institution. Colorectal serrated lesions were pathologically divided into 3 groups: hyperplastic polyp (HP), sessile serrated adenoma/polyp (SSA/P), and traditional serrated adenoma (TSA). SSA/P was detected frequently in the right colon and SSA/P was mainly flat-elevated. Cancers occurring in SSA/P were found more frequently than HP or TSA. The incidence of cancer in SSA/P was equivalent to that of cancer in traditional adenoma. Further studies are warranted to clarify clinicopathological features of serrated lesions of the colorectum.     

Granulocyte Colony-stimulating Factor-induced Aortitis with Lung Injury,Splenomegaly, and a Rash During Treatment for Recurrent Extraosseous Mucinous Chondrosarcoma

We herein report a case of aortitis induced by granulocyte colony-stimulating factor (G-CSF) that coincided with lung injury, splenomegaly, and cutaneous manifestations during treatment for recurrent extraosseous mucinous chondrosarcoma. Computed tomography revealed large-vessel vasculitis, splenomegaly, and pulmonary interstitial changes. Treatment with prednisolone was successful. Because sarcoma is a rare disease, this case is valuable for showing clinicians that G-CSF preparations could cause aortitis regardless of the patient''s underlying diseases or therapeutic pharmacological backgrounds.     

Ossification of the ligamentum flavum of the thoracic spine in adult kyphosis

Summary Ossification of the ligamentum flavum has been recognised as a definite clinical entity as is ossification of the posterior longitudinal ligament. The incidence of both is high in Japan. This study demonstrates that the incidence of ossification of the ligamentum flavum in persons who have a kyphosis of the thoracic or lumbar spine is higher than in those who do not. It is considered that localised mechanical stress affecting the ligamentum flavum is a contributing factor to the development of ossification, together with the generalised factors which may favour bone formation. However, the aetiology of this lesion is still obscure as is that of ossification of the posterior longitudinal ligament.

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Résumé L'ossification du ligament jaune représente une entité clinique définie, de même que celle du ligament longitudinal postérieur. Les deux affections sont fréquentes au Japon. Cette étude montre que l'ossification du ligament jaune s'observe plus souvent chez les sujets qui présentent une cyphose dorsale ou lombaire. On peut penser que les contraintes mécaniques localisées au ligament jaune constituent un facteur contribuant au développement de l'ossification, et s'ajoutant aux facteurs généraux susceptibles de favoriser la formation osseuse. Cependant, l'étiologie de cette affection demeure mystérieuse de même que l'ossification du ligament longitudinal postérieur.

     

A case of rapid progressive glomerulonephritis with IgA deposits after renal transplantation

Shimizu T, Tanabe K, Tokumoto T, Shimmura H, Koga S, Ishikawa N, Oshima T, Toma H, Yamaguchi Y. A case of rapid progressive glomerulonephritis with IgA deposits after renal transplantation. Clin Transplantation 2001: 15 (Supplement 5): 11–15. ©Munksgaard, 2001
A 46-yr-old Japanese male who underwent a second cadaveric kidney transplantation on 31 October 1996 after suffering Type II diabetic mellitus for 25 yr was admitted to our institute on 23 January 1999, because of colicky abdominal pain and abdominal discomfort. Elevated levels of serum creatinine, severe proteinuria and microscopic haematuria were observed. The allograft biopsy specimen disclosed crescentic glomerulonephritis. Immunofluorescence showed granular deposits of mainly IgA and C3 along glomerular capillary walls and mesangial areas. Electron microscopy showed extensive subepithelial and mesangial electron dense deposits. Rapid and irreversible worsening of graft function led to resumption of haemodialysis on 31 May 1999. We speculated that this case was an atypical form of de novo Henoch–Schönlein purpura nephritis (HSPN) in transplanted kidney because of the histopathological findings of the allograft biopsy and clinical symptoms.     

Complete response to treatment with hepatic arterial infusion of cisplatin powder (IA-call) in a case of hepatocellular carcinoma with multiple lung metastases]

A 74-year-old woman was admitted to our hospital to treat her hepatocellular carcinoma (stage IVB) with multiple lung metastases. She was treated with 3 times of hepatic arterial infusion of cisplatin powder (IA-call). After the treatment, liver mass and lung tumors were disappeared and high levels of tumor markers (AFP and PIVKA-II) were markedly decreased. These data revealed that a complete response (CR) was obtained for her. She has still been maintained in CR for 2 years since the first treatment.     

Diagnosis of vasospastic angina by hyperventilation and cold-pressor stress echocardiography: comparison to I-MIBG myocardial scintigraphy.

OBJECTIVES: We assessed the usefulness of hyperventilation and cold-pressor stress echocardiography in the diagnosis of vasospastic angina compared with that of iodine-123 metaiodobenzylguanidine (123I-MIBG) myocardial scintigraphy. BACKGROUND: Various noninvasive methods have been used to detect vasospastic angina, but they are not very sensitive in the diagnosis of vasospastic angina. 123I-MIBG images and stress echocardiography have recently been proposed as a useful tool for detecting vasospastic angina. METHOD: Thirty patients (21 males and 9 females, mean age: 52 +/- 14 years) who complained of rest angina were enrolled for this study. The hyperventilation and cold-pressor stress echocardiography test consisted of hyperventilation for 6 minutes, followed by cold water pressor for 2 minutes under continuous electrocardiographic and echocardiographic monitoring. Left ventricular regional wall motion by echocardiogram was analyzed by using the 16-segment model, and wall motion ranging from normokinesis to dyskinesis was evaluated visually in each segment. Single-photon emission computed tomography images of 123I-MIBG myocardial scintigraphy were divided into 26 segments. Defect scores were established using the 4 grades. The echocardiographic criteria for coronary spasm was worsening wall motion and the scintigraphic criteria was defect score more than moderately reduced. Acetylcholine was selectively injected into the right coronary artery (20 microg and 50 microg) and left coronary artery (20 microg, 50 microg, and 100 microg). RESULTS: Of 30 patients, 20 patients had coronary spasm on coronary angiography with an intracoronary injection of acetylcholine, whereas 10 patients showed no spasm. Multivessel spasms were observed in 15 patients. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of hyperventilation and cold-pressor stress echocardiography for diagnosing in patients with vasospastic angina were 90%, 90%, 95%, 82%, and 90%, respectively. However, those of 123I-MIBG myocardial scintigraphy for diagnosing in patients with vasospastic angina were 90%, 40%, 75%, 67%, and 73%, respectively. The specificity of hyperventilation and cold-pressor stress echocardiography was significantly higher than that of 123I-MIBG myocardial scintigraphy (P <.05). CONCLUSION: The specificity of hyperventilation and cold-pressor stress echocardiography in diagnosing coronary spasm were higher than that shown by 201I-MIBG myocardial scintigraphy.