Anterior segmentectomy with caudate lobectomy for hilar cholangiocarcinoma.

When hepatic resection for hilar chol-angiocarcinoma with impaired hepatic function is performed, minimal resection of the involved segment on the basis of the extent of cancer invasion must be selected so as to minimize the risk of postoperative hepatic failure. We describe our experience with anterior segmentectomy with caudate lobectomy for hilar cholangiocarcinoma in two patients with impaired hepatic function and poor general health. These procedures were curative resections histologically, and were not followed by severe postoperative complications. Anterior segmentectomy together with caudate lobectomy was considered appropriate treatment for hilar cholangiocarcinoma without infiltration of the posterior hepatic branch in patients with impaired hepatic function.

A case of ruptured mesenchymal chondrosarcoma of the pancreas.

A 25-year-old woman who underwent surgical removal of a right frontal meningeal mesenchymal chondrosarcoma in 1980 manifested abdominal pain and progressive anemia after a traffic accident in April 1997. CT disclosed a well-enhanced solid mass 2.5 cm in diameter with internal calcific deposits at the tail of the pancreas and a surrounding hematoma of 5.5 cm in diameter. Surgical resection revealed a ruptured metastatic mesenchymal chondrosarcoma of the pancreas.

Pancreaticojejunostomy and pancreatic leakage after pancreaticoduodenectomy.

Some techniques of pancreaticojejunostomy have been introduced with reference to pancreatic leakage from the pancreaticojejunal anastomosis. Pancreatic leakage (+/- ) occurred in 21.4% of pancreaticojejunostomy patients and pancreatic leakage (+) in 9.5%. The frequency of pancreatic leakage tended to be higher in cases where the pancreatic duct was undilated and the remaining distal segment of the pancreas had a soft tissue. Pancreatic leakage led to secondary complication in none of the patients in our series, but further technical refinement of pancreaticojejunostomy is warranted to reduce the frequency of pancreatic leakage to zero.

Diagnostic and therapeutic strategies of pyogenic liver abscess.

The infectious routes and etiologies of 26 cases with pyogenic liver abscess were portal spread in one, hematogenous in three, biliary in 12, transarterial embolization (TAE) in three, posthepatectomy in one and cryptogenic in five cases. Portal and hematogenous cases tend to show solitary and cystic pattern on echogram, and the majority of the bacteria detected was Klebsiella. While most biliary cases show multiple and cystic with tumor pattern on echogram, and an unhomogeneous low density in CT feature, anaerobic bacteria and candida were isolated only from the biliary or TAE cases. Most cases could be cured completely by the various kinds of abscess drainage, but two TAE cases with PTAD (percutaneous transhepatic abscess drainage) and two biliary cases with PTBD (PT-biliary drainage) and PTAD died due to a delay in establishing a diagnosis and to the severity of the condition. An early diagnosis followed by PTAD or PTBD were thought to be of prime importance.

Radiotherapy-centered multimodal treatment of unresectable pancreatic carcinoma.

Multimodal treatment procedures, including intraoperative and external beam radiotherapy, chemotherapy and hyperthermotherapy, used for treatment of unresectable pancreatic carcinoma for the past two years have been described. Among the ten progressive cases where multimodal treatment was applied, marked reduction in tumor mass was observed in three cases. The cases receiving such treatment reported prolonged survival, the median survival period being 250 days as compared with 85.4 days in the non-multimodal group. The conclusion is that optimal palliative effects can be achieved by sustained application of both intraoperative and postoperative radiotherapy, hyperthermia and other techniques of multimodal therapy in cases of unresectable pancreatic carcinoma.

[Effect of PMU therapy (CDDP, MMC and UFT) against terminal gastric carcinoma. Hokuriku Cisplatin Round-table Conference].

PMU therapy with 75 mg/m2 of CDDP, 10 mg/body of MMC and 400 mg/day of UFT was performed on 57 patients with terminal gastric carcinoma. The treatment resulted in CR in 2, PR in 9, MR in 1, NC in 16 and PD in 9 of 37 patients with evaluable cases, with a response rate of 30% (11/37 patients). In the 11 responders, the mean disease-free interval was 6.6 months with a median interval of 5 months, and the mean survival period was 9.2 months with a median survival period of 6 months, while in the 46 non-responders, the mean survival period was 6.7 months with a median survival period of 5 months. In all patients, the mean survival period was 7.1 months with a median survival period of 6 months. Adverse reactions to the treatment included gastrointestinal disturbance observed in 77%, nephrotoxicity in 14%, and myelotoxicity in 26% of the patients, but all reactions became normalized during the course of observation. These results have led to the conclusion that PMU therapy may be an effective treatment for terminal gastric carcinoma.

[Modes of spread and surgical strategy for gallbladder carcinoma with subserosal invasion].

The mode of spread and the prognosis were investigated in 22 patients with resected gallbladder carcinoma invading the subserosal layer. By the Kaplan-Meier method, the 5-year survival rate was 68.8% in patients receiving curative or relatively noncurative resection. On the other hand, no patient survived for more than 3 years after noncurative resection. The mode of subserosal infiltration was classified according to the general rules for gastric cancer study. At least systemic lymph node dissection (R2) should be performed in patients with ss alpha cancer, because lymph node metastasis in these patients were confined to the 1st group. More extensive lymph node dissection (R2 with 9, 16) is essential for patients with ss beta and ss gamma, because lymph node metastasis to at least the 2nd group were seen in 75% of them. The surgical margin was positive for cancer in all patient with infiltration of the hepatoduodenal ligament. Therefore, it was considered that hepatoligamentectomy should be performed in these patients to obtain a cancer free surgical margin. Among patients undergoing curative or relatively noncurative resection, the recurrence rate was 43% in those with lymph node metastasis and 50% in those with DNA aneuploidy. Therefore, it appears that adjuvant chemotherapy should be given to such patients.

Cryopreservation of hamster pancreatic islets using a rapid cooling rate.

To clarify the possibility of developing a rapid cooling rate for islet cryopreservation, we used a cooling rate of 25 degrees C/min for hamster pancreatic islet cryopreservation using 15 per cent dimethylsulfoxide as a cryoprotectant. After preservation, these islets were examined for their morphology and function by assaying the insulin release after glucose stimulation and the contents of the insulin and DNA in 10 islets. In addition, islet cell replicatory activity was investigated by an autoradiographic technique. The effects of transplantation of the islets upon isogeneic and xenogeneic transplantation were also examined. Freezing using a rapid cooling rate of 25 degrees C/min was found to be as effective as a slow cooling rate of 1 degree C/min for hamster islet cryopreservation. Morphologically, the cryopreserved islets appeared to be similar to the non-frozen cultured islets. The glucose-stimulated insulin release and cell replicatory activities in vitro also remained unchanged, whereas the number of cells per islet decreased slightly after cryopreservation. The grafting of cryopreserved islets normalized streptozotocin induced hyperglycemia following isogeneic transplantation. On the other hand, no prolongation of graft survivals in the case of the xenogeneic transplantation of hamster islets to rats was observed. The isogeneically transplanted islets exhibited the same cell replicatory activities in vivo, which was even higher compared that of normal hamster pancreatic islets in situ. In conclusion, the present findings indicate that hamster pancreatic islets can be successfully cryopreserved using a rapid cooling rate, however, it does not appear that this treatment reduces islet vulnerability to xenogeneic graft rejection.

Postoperative complications and survival after pancreatoduodenectomy in patients aged over 70 years.

An analysis of postoperative complications and survival was conducted in 31 patients undergoing pancreatoduodenectomy (PD) for carcinoma of the pancreas or periampullary carcinoma. Of them, 11 were over 70 years of age and 20 were under 70. Anastomotic leakage was the most common complication after PD. Definite pancreatic leakage was found in one patient in the over 70 group, and one case each of pancreatic, biliary, and gastric leakage were found in the under 70 group. All complications were treated conservatively without any further operative intervention. The overall morbidity rate was 41.9% (13/31), being 45.5% (5/11) in the over 70 group and 40.0% (8/20) in the under 70 group, and no operative deaths occurred within 30 days after surgery. The cumulative survival rate of the patients aged over 70 years with carcinoma of the pancreas or periampullary carcinoma did not differ significantly from the rate of those under 70. It was thus concluded that PD achieves an adequate prognosis and survival in patients over 70 years of age.

Experimental studies on cryopreservation combined with the cultural process of isolated rat pancreatic islets.

Recently many investigators have attempted transplantation of isolated islets of Langerhans in an expectation of therapeutic effects in patients with diabetes. In the course of time, preservation of the islets was found to be a prerequisite for successful transplantation. In the present studies, we used our newly designed method of preserving islets, i.e., cryopreservation combined with the cultural process before and after freezing, and we examined the insulin-releasing activity of the islets and attempted transplantation of the islets so-obtained. As to the insulin-releasing activity, the islets cryopreserved after short-term culture increased insulin output as compared with those cryopreserved without culture. Damage to Langerhans' islets resulting from isolation and cryopreservation was overcome during the culture. Transplantation of Langerhans' islets cultured for 3-4 days before and after the cryopreserving process produced favorable results.

A case of duodenal carcinoma presenting as a submucosal tumor.

This paper describes a patient with duodenal carcinoma showing the features of a submucosal tumor, leading to difficulty in making an accurate preoperative diagnosis. A 63-year-old woman was admitted for investigation of a duodenal mass. An examination of the upper gastrointestinal tract revealed a semicircular compression of the stomach and the duodenum. Endoscopy of the stomach and duodenum disclosed a hemispherical tumor with a deep ulcer in the apex. Computer tomography revealed a tumor of about 5 cm in diameter at the same site. Laparotomy was performed under the tentative diagnosis of a submucosal tumor. A tumor was found occupying the duodenum, which compressed the gastric antrum exteriorly, and was also adherent to the head of the pancreas by direct invasion. A curative resection was performed by combining a pancreatoduodenectomy with a transverse colectomy along with regional lymph node clearance. A microscopic examination showed that the tumor contained neoplastic cells growing in a tubular pattern, particularly in its peripheral regions. Thus, this lesion was finally diagnosed as primary adenocarcinoma of the duodenum.