Extraperitoneal Fluid Collection due to Chronic Pancreatitis.

A 39-year-old man was referred to our hospital for the investigation of abdominal fluid collection. He was pointed out to have alcoholic chronic pancreatitis. Laboratory data showed inflammation and slightly elevated serum direct bilirubin and amylase. An abdominal computed tomography demonstrated huge fluid collection, multiple pancreatic pseudocysts and pancreatic calcification. The fluid showed a high level of amylase at 4,490 IU/l. Under the diagnosis of pancreatic ascites, endoscopic pancreatic stent insertion was attempted but was unsuccessful, so surgical treatment (Frey procedure and cystojejunostomy) was performed. During the operation, a huge amount of fluid containing bile acid (amylase at 1,474 IU/l and bilirubin at 13.5 mg/dl) was found to exist in the extraperitoneal space (over the peritoneum), but no ascites was found. His postoperative course was uneventful and he shows no recurrence of the fluid. Pancreatic ascites is thought to result from the disruption of the main pancreatic duct, the rupture of a pancreatic pseudocyst, or possibly leakage from an unknown site. In our extremely rare case, the pancreatic pseudocyst penetrated into the hepatoduodenal ligament with communication to the common bile duct, and the fluid flowed into the round ligament of the liver and next into the extraperitoneal space.

Metastatic neck disease beyond the limits of a neck dissection: attention to the 'para-hyoid' area in T1/2 oral tongue cancer.

OBJECTIVE: We evaluated patients with small oral tongue cancer suffering from recurrence, which develops in the intervening area between the primary site and the neck. Lesions in the area around the cornu of the hyoid bone ('para-hyoid' area) often involve the hypoglossal nerve and the root of the lingual artery, resulting in treatment failure and death. METHODS: A 10-year retrospective chart review was conducted of 248 oral tongue cancer patients with small primary tumors (T1/2). No patients who underwent postoperative radiotherapy (PORT) were included. RESULTS: After excluding those who had local failure or developed new primary lesions, 6.3% of the patients were noted to have a para-hyoid lesion. A similar incidence was observed between the patients with and without previous neck dissection, 6.9% and 5.7%, respectively. All but one patient died due to uncontrolled neck disease. CONCLUSIONS: Recurrent para-hyoid lesions could occur, irrespective of a previous neck dissection. In other words, the para-hyoid area is beyond the limits of a neck dissection. Once a para-hyoid lesion becomes clinically evident, it seems difficult to salvage. Therefore, a careful inspection of the area should be included intraoperatively in any type of neck dissection (i.e. elective or therapeutic) for patients with oral tongue cancer. This may be the key to improving the regional control rate of patients with small oral tongue cancer. We believe that some patients will benefit from more aggressive treatment of the neck, although PORT seems unnecessary for the majority of the patients with limited neck disease.

A new flap design for tongue reconstruction after total or subtotal glossectomy in thin patients.

OBJECTIVE: For tongue reconstruction after total or subtotal glossectomy, a rectus abdominis musculocutaneous flap is often used to obtain sufficient flap volume. However, thin patients often have too little fat tissue to ensure adequate flap volume. For this reason we developed a new flap design to compensate for insufficient flap volume in thin patients. METHODS: In this series, total or subtotal glossectomy was performed in 20 thin men with a mean age of 58.3 years. The patients had a mean body mass index of 18.22 kg/m(2) and most were considered emaciated. The defects were reconstructed using a rectus abdominis musculocutaneous flap with two skin islands. The first skin island was used to reconstruct the mucosal defect, and the second was de-epithelialised and used to increase flap volume. RESULTS: Flaps were transferred successfully in 19 out of 20 patients. Most patients could tolerate more than a soft diet without severe aspiration and could engage in conversation. However, four patients required total laryngectomy or a permanent stoma owing to severe aspiration. In this series, the larynx could be preserved in 80% of thin patients, and satisfactory postoperative oral function was obtained. CONCLUSION: The most important point for obtaining satisfactory oral function is to reconstruct a tongue with a protuberant shape and sufficient volume. We could maintain sufficient flap volume with the de-epithelialised skin island of a rectus abdominis musculocutaneous free flap. We believe our new flap design is effective for tongue reconstruction in thin patients.

Accelerated radiotherapy and larynx preservation in favorable-risk patients with T2 or worse hypopharyngeal cancer.

OBJECTIVE: To evaluate the advantage of accelerated fractionation radiotherapy for patients with hypopharyngeal cancer requiring total laryngectomy. METHODS: Seventy patients with previously untreated, technically resectable hypopharyngeal cancer who received larynx-preserving treatment with radiotherapy between April 1992 and June 2004 were analyzed. No patients had previous history of other malignancy or poor performance status that would possibly affect the outcomes. A total RT dose of > or = 60 Gy/6 weeks was determined depending on the tumor clearance during treatment before December 1998, and fixed to 70 Gy in all patients thereafter. Accelerated fractionation (70 Gy/<49 days) was completed in 35 patients during the latter period. Concomitant platinum-based chemotherapy was used in 41 patients after May 1998. RESULTS: Local control rates at 2 years were 72 and 68% for patients with T2 and T3/T4 disease, respectively. Patients who had received 70 Gy/<49 days achieved a better local control rate than those who had received other, more conservative total dose/overall treatment time with statistical significance (91% versus 50% at 2 years, P < 0.001). Multivariate analysis involving 70 Gy/<49 days of radiotherapy, T-classification (T2 versus T3/4), and use of chemotherapy revealed that administering 70 Gy/<7 weeks was the only independent prognostic factor (P = 0.007) for better local control. CONCLUSIONS: Our experience in radiotherapy for hypopharyngeal cancer mirrored the results of previously conducted large randomized trials for various head and neck cancers. Encouraging local control in this study warrants prospective study to test the long-term oncological and functional outcome of larynx-preserving treatment in patients with advanced but resectable volume of this disease.

Palliative total pharyngo-laryngo-esophagectomy.

OBJECTIVE: To evaluate the outcomes of total pharyngo-laryngo-esophagectomy (TPLE) as a palliative procedure for achieving oral intake without tube placement. BACKGROUND: Patients with head and neck cancers require airway maintenance achieved by the placement of a tracheostomy tube and nutrition provided through a gastric fistula or a central vein, which may markedly decrease the quality of life (QOL) of the patients. CASES: Two patients with cervical esophageal cancer are described. The first patient was a 69-year-old male with cervical esophageal cancer with vertebral invasion, for which complete resection was not possible. Following TPLE, oral intake was initiated on post-operative day 9 and was maintained for 138 days. The second patient was a 73-year-old male with recurrent cervical esophageal cancer and unresectable lymph node metastasis for which lymph node dissection was not applicable. Following TPLE, oral intake was initiated on post-operative day 7 and was maintained for 199 days. Both patients were satisfied with the outcome. CONCLUSIONS: The QOL of the two patients was improved following the restoration of oral intake ability. Palliative TPLE may be appropriate for patients with advanced head and neck cancers.

Surgical management of carcinoma of the cervical esophagus.

OBJECTIVES: The aim of the present study was to clarify the clinicopathological characteristics, reconstruction methods after resection, and prognosis of cervical esophageal squamous cell carcinoma. METHODS: Seventy-four with squamous cell carcinomas of the cervical esophagus not previously treated who underwent cervical esophagectomy or total esophagectomy with or without laryngectomy were retrospectively analyzed. RESULTS: The operative morbidity and in-hospital mortality rates were 34% (25 patients) and 4% (3 patients), respectively. Alimentary continuity was achieved with free jejunal transfer (50 patients), gastric pull-up (19 patients), and other procedures (5 patients). The frequencies of postoperative complications and death did not differ between free jejunal transfer and gastric pull-up. The overall 3- and 5-year survival rates were 42% and 33%, respectively. The significant clinicopathological factors affecting survival were patient gender, high T factor, lymph node involvement, palpable cervical lymph nodes, vocal cord paralysis, lymphatic invasion, and extracapsular invasion. The pattern of first failure was most often locoregional (82%, 36 patients). CONCLUSION: The choice of free jejunal transfer or gastric pull-up for reconstruction after surgical resection of cervical esophageal carcinoma depends on the degree of tumor extension. Adverse factors affecting survival should be considered when candidates for the surgery are selected.

Genetic polymorphisms of alcohol and aldehyde dehydrogenases, and drinking, smoking and diet in Japanese men with oral and pharyngeal squamous cell carcinoma.

The genetic polymorphisms of aldehyde dehydrogenase-2 (ALDH2), alcohol dehydrogenase-1B (ADH1B, previously called ADH2), and ADH1C (previously called ADH3) affect the metabolism of alcohol. The inactive ALDH2 encoded by ALDH2*1/*2 and the less-active ADH1B encoded by ADH1B*1/*1 increase the risk of esophageal squamous cell carcinoma in East Asian drinkers. This case-control study involved 96 Japanese men with oral and pharyngeal squamous cell carcinoma (hypopharyngeal cancer in 43 patients and oral/oropharyngeal cancer in 53) and 642 cancer-free Japanese men. The risk of the cancers overall and of hypopharyngeal cancer was increased 3.61- and 10.08-fold, respectively, by ALDH2*1/*2 among moderate-to-heavy drinkers (9+ units/week; one unit = 22 g of ethanol), but the risk of oral/oropharyngeal cancer was not significantly affected by the ALDH2 genotype. The results obtained with a simple alcohol flushing questionnaire were essentially comparable with those obtained by ALDH2 genotyping. Among moderate-to-heavy drinkers, men with the less-active ADH1B*1/*1 had a significantly higher risk of the cancers overall, of hypopharyngeal cancer, and of oral/oropharyngeal cancer (OR = 5.56, 7.21 and 4.24, respectively). In view of the linkage disequilibrium between ADH1B and ADH1C, the ADH1C genotype does not significantly affect cancer risk. The significant independent risk factors for oral and pharyngeal cancer overall among moderate-to-heavy drinkers were inactive ALDH2*1/*2, less-active ADH1B*1/*1, frequent drinking of strong alcohol beverages straight, smoking, and lower intake of green-yellow vegetables. Educating these risks for cancer of the upper aerodigestive tract could be a useful new strategic approach to the prevention of these cancers in Japanese.