Diagnosis of Small Pancreatic Carcinoma

A retrospective analysis was performed to evaluate the clinicalsymptoms and abnormal test findings in small pancreatic carcinoma.Five hundred and thirty-six cases of pancreatic carcinoma withthe histology of duct cell carcinoma were collected from 14medical centers in Japan. In 440 of the cases, tumor size wasmeasured at the time of laparotomy or from the resected specimen.Three hundred and seventy-seven patients (86%) had a carcinomalarger than 3.0 cm; only 30% of these were resectable. Sixty-threepatients (14%) had a carcinoma of 3.0 cm or less, with resectabilityof 97%. Detecting a tumor of "3 cm or less" with a high probabilityof resectability is the objective of early diagnosis with theresulting possibility of a cure. In most cases these small carcinomaswere found easily when obstructive jaundice was present (73%).However, the estimated occurrence of obstructive jaundice associatedwith carcinomas of 3 cm or less was only 10% among the totalcases of pancreatic carcinoma studied. Therefore, it is necessaryfor early diagnosis to detect carcinomas of 3 cm or less presentingwithout jaundice. The symptoms of small carcinoma without jaundiceare weight loss, anorexia, upper abdominal pain, back pain anda palpable abdominal mass. Among the various available examinations,endoscopic retrograde cholangiopancreatography, computerizedtomography and ultrasonography were valuable in diagnosing thesesmall carcinomas.     

Laparoscopic Cholecystectomy in Patients with Previous Gastrectomy

Abstract: This study was designed to assess outcome, morbidity and mortality in patients with a previous history of gastrectomy who underwent laparoscopic cholecystectomy at Teikyo University Hospital at Mizonokuchi. From May 1990 through April 1995, 18 patients who had an upper midline incision from previous gastric surgery underwent attempted or successful laparoscopic cholecystectomy. Previous gastric operations included subtotal gastrectomy with Billroth l/ll anastomosis for ulcer diseases and total gastrectomy with jejunal interposition for gastric cancer. Preoperative ultrasound was done in all cases, ERCP in nine cases and drip infusion cholangiography in three cases to assess and evaluate the biliary system. Intraoperative cholangiography was done in the latter eight cases. Laparoscopic cholecystectomy was successful in all but one patient who had severe adhesions necessitating conversion to an open cholecystectomy. Overall results were very similar in patients with and without a previous history of gastric surgery who underwent laparoscopic cholecystectomy at this institution. It was also found that intraoperative difficulties and a prolonged operative time did not correlate with the nature of the previous operation, but rather with the severity of adhesions identified during surgery. Although the number of cases in this study was very small, the results indicate that if the surgeon is experienced and well prepared patients with a previous history of gastrectomy can also undergo laparoscopic cholecystectomy safely and with maximum benefit. We conclude that these patients should not be denied the advantages of laparoscopic cholecystectomy. A trial laparoscopic procedure is warranted although the conversion rate to open cholecystectomy may be high.     

Combination of Preoperative EST,Laparoscopic Cholecystectomy with Choledochotomy,and Postoperative Cholangioscopy in the Treatment of Common Bile Duct Stones

A case of common duct stones, successfully managed with a combination of preoperative EST, laparoscopic choledochotomy and postoperative choledochoscopic stone extraction, is reported. A 32-year-old man was admitted to our hospital because of jaundice and right hypochon-dralgia of several-days' duration. CT, US and ERCP revealed stones in the gallbladder and common bile duct. EST was performed to remove the stones in the common bile duct prior to laparoscopic cholecystectomy. However, the patient developed pancreatitis as a complication of EST, which was successfully managed by conservative therapy. Though some stones remained in the common duct following the first trial of EST, the patient rejected a second round of EST. Laparoscopic cholecystectomy and choledochotomy were performed to remove the gallbladder and the stones remaining in the common bile duct. A T tube was placed in the incised common bile duct for management of possible retained stones. Twenty days after the surgery, successful postoperative cholangioscopy was performed, and the stones remaining in the common duct were removed. Hyperamylasemia and pancreatitis are relatively common complications of EST occurring in about 7% of cases, but only 3% of these patients experience severe pancreatitis, requiring hospitalization. Conservative therapy is always the treatment of choice. In our particular patient, pancreatitis caused by EST was successfully managed by decompression with ENBD and administration of ulinastatin. Residual stones in the CBD were completely removed by laparoscopic common bile duct exploration following EST and postoperative cholangioscopy through the T tube fistula.     

A Case with Intrahepatic Stones followed up for Over 22 Years after Complete Cholangioscopic Stone Extraction

Abstract: In this paper, we describe the technological know-how, diagnostic and therapeutic significance of cholangioscopy. In addition, a case who had had recurrent stones after 22 years in the sites different to those of the previous stones was presented, and therapeutic strategy for the management of intrahepatic stones was discussed. The main value of cholangioscopy lies in the fact that retained or unsuspected stones are readily removed with endoscopically-guided instruments. Moreover, cholangioscopy not only resolves the question as to the presence or the absence of stones, but also indicates inflammation or minute carcinomatous lesions in the biliary tract which would otherwise go undetected. Percutaneous transhepatic cholangioscopy is especially useful for management of intrahepatic stones, because it provides very important information on the location and extent of lesions which is necessary for deciding appropriate therapeutic procedures. The authors firmly believe that better therapeutic results of biliary surgery can be expected if this reliable endoscopic approach becomes more routinely used by surgeons. (Dig Endosc 1999; 11: 169–173)     

Tuberculosis of the Esophagus

A case of tuberculosis of the esophagus is presented in a patient with pulmonary tuberculosis. The patient, complaining of dysphagia, had esophagoscopic examination which showed a submucosal tumor with central ulceration. Tissue biopsy, under direct vision from the tumor mass, confirmed the diagnosis of tuberculosis. The patient has been asymptomatic under treatment. Both esophageal and pulmonary lesions are largely improved.
The rarity of the lesion and necessity of taking biopsy are emphasized.     

Pancreatic Carcinoma Difficult to Differentiate from Duodenal Carcinoma

A case of carcinoma of the uncinate process of the pancreas that was clinically misdiagnosed as primary carcinoma of the duodenum is reported. This is a rare case because the cancer infiltrated the duodenum producing a large tumor with central ulceration, well-defined rolled-up margins giving the appearance of a typical gut adenocarcinoma. Although the carcinoma of the pancreas is more common than the duodenal carcinoma, we wish to describe why the misdiagnosis has been made.     

Experience with Laparoscopic Appendectomy —The Technique and Our Views of its Indications—

Abstract: Since June, 1991 a laparoscopic appendectomy (LA) was performed on eleven patients with suspected appendicitis which could not be confirmed by the conventional diagnostic methods. The patients included 7 males and 4 females, with a mean age of 27, 9, ranging from 16 to 46 years. No postoperative complications were encountered. The laparoscopic diagnoses included gangrenous appendicitis in 2, suppurative appendicitis in 2, catarrhal appendicitis in 4, salpingitis in 2 and an appendiceal mass in one patient (Case 7). Histopathological diagnoses were phlegmonous appendicitis in 3, mucinous cystadenoma in one and catarrhal appendicitis in 7 patients. Two cases of salpingitis and a case with ovarian bleeding were treated conservatively after incidental laparoscopic removal of the appendix. Case 7 was histopathologically diagnosed as having mucinous cystadenoma. The patients’postoperative hospital stay was from 5 to 8 days, with an average of 6.9 days. All patients had been given the permission to be discharged by the third POD but they stayed longer because of benefits given by the health insurance system very specific to Japan. LA in our clinic has so far been limited to selected patients in whom the diagnosis of appendicitis could not been confirmed and laparoscopic examination was indicated, mainly due to manpower problems involving surgeons, anesthetists and operating room nurses. However, LA provides not only benefits for patients but also several merits for surgeons including better exposure of the operating field in most cases when compared with an open appendectomy. We feel, therefore, that the indications for LA might be extended more widely, probably to most cases of appendicitis.     

Progression of radiological changes in relapsing and chronic pancreatitis

Progression of radiological changes was noted in 19 (22.1%) of 86 cases of relapsing or chronic pancreatitis followed by serial pancreatograms. The initial feature of chronic pancreatitis was focal minimal pancreatitis, characterized by an irregular dilatation of several side branches on the pancreatogram. Some patients with focal minimal pancreatitis demonstrated progression of the extent and severity of changes only in side branches while others progressed further to moderate or advanced chronic pancreatitis showing changes in the main pancreatic duct. Most of the progressive cases were alcoholic, and some showed progression to advanced pancreatitis within 4 years. Rapid progression of radiological changes was associated with relapses of acute pancreatitis. No remarkable changes were observed in many non-alcoholic patients, whereas some cases complicated with gallstones showed progression of disease in the side branches during a follow-up period of 3-7 years.