Use of disposable stapler in operative cystogastrostomy for pancreatic pseudocyst.

Surgical stapling techniques are widely used in gastrointestinal surgery. These procedures are excellent in convenience and safety. We describe here a new practical application of the surgical disposable stapler, Auto Suture Premium Plus CEEA 34 circular stapler, for the operative drainage of a large symptomatic pancreatic pseudocyst. A 68 year-old man underwent an operative cystogastrostomy using this instrument. His post-operative recovery was uneventful. He is free from symptoms, and abdominal tomography shows complete disappearance of the cystic cavity. We believe that this is the first clinical paper that reports on the stapled cystogastrostomy. This instrument is very useful for creating a stapled cystogastrostomy, similar to one created in the standard open approach.

A case of biliary cystadenocarcinoma arising in the liver with a congenital retention of indocyanine green.

A case of biliary cystadenocarcinoma that occurred in a 45-year-old woman is reported. Ultrasonography and computed tomography clearly revealed papillary projections in the cyst of the liver. Percutaneous transhepatic cystography showed connection between the cyst and the common bile duct. The tumor was surgically resected and proved to be a mucinous papillary adenocarcinoma arising from a biliary cystadenoma. The patient is doing well 4 years after surgery. Interestingly, this is the first reported case of a biliary cystadenocarcinoma in the liver with markedly diminished excretion of indocyanine green.

Allogeneic inhibitory activity of regional lymph node cells in the mouse isografted with methylcholanthrene-induced tumor.

In mouse bearing progressive cancer a decrease was present in the allogeneic inhibitory activity of T-lymphocytes, which constitutes the core of immunological surveillance system in mammalians. For tests, methylcholanthrene-induced tumor (MC-tumor) was isografted subcutaneously on the back between scapulae of C3H mice, and the lymphocytes were prepared from the regional axillary lymph nodes removed from these mice at 1, 2, 3, or 4 weeks after grafting. These lymph nodes cells were cultured together with 40-fold numbers of allogeneic JTC-11 cells derived from Ehrlich cancer cells in a culture medium containing 2.0% (v/v) PHA for 24 or 48 hours. The proliferation rate of JTC-11 cells (increased numbers) at weekly interval was considered the allogeneic inhibitory activity of lymph node cells. As a result it was demonstrated that in the early stage after tumor transplantation, i.e., in the first or second week, regional lymph node cells showed a strong allogeneic inhibitory activity, as in the case with lymph-node cells from normal mice, but at progressive stage of cancer, i.e., the third or fourth week when tumors were larger, such activity was completely lost. It seems that mice with progressive cancer showed a decrease of allogeneic inhibitory activity, i.e., a disruption of homeostasis was present.

Cancer immunotherapy with surgery.

With the recent advances in the immunological surveillance system, an understanding of the role of host immunity has become essential to the management of carcinogenesis, tumor proliferation, recurrence and metastasis. Although it is important to continue chemical and surgical treatment of cancer, support of the anti-tumor immune system of the host should also be considered. Long term remission has been reported in leukemia by treating with BCG after chemotherapy whereas surgical treatment is usually more effective in preventing cancer recurrence in digestive organ cancer. The first step is extirpating the tumor as thoroughly as possible and the second step is chemo-immunotherapy. Cancer immunity, however weak, constitutes the basis for other treatments in selectively attacking cancer cells remaining after surgery, chemotherapy or irradiation. Immunotherapy should thus not replace chemotherapy or radiotherapy, but these methods should be employed in combination to attain more favorable results.

A case of primary retroperitoneal mucinous cystadenocarcinoma.

A rare case of primary retroperitoneal mucinous cystadenocarcinoma in a 44-year-old woman is reported. The cystic tumor was delineated by CT and echography. The tumor was removed intact in the presence of bilateral normal ovaries and demonstrated an infiltrating malignant process. This neoplasm may have arisen from a supernumerary ovary. The patient died of recurrence 4 months after surgery. A comparison of the known cases indicates that aggressive treatment by hysterectomy with bilateral salpingo-oophorectomy in addition to cyst extirpation may improve prognosis.

A case of giant cavernous hemangioma of the liver complicated by intravascular coagulopathy.

A case of liver hemangioma complicated by intravascular coagulopathy is presented because of the rarity of the association. Hemangioma of the liver was suspected by palpation of the liver tumor, scintigraphy and x-ray examination, and confirmed by selective hepatic arteriography in combination with exploratory laparotomy. Intravascular coagulopathy was established by demonstrating secondary fibrinolysis and consumption of platelets and coagulation factors. Unconjugated hyperbilirubinemia due to micro-angiopathic hemolytic anemia was also present. The clinical course of the clotting abnormalities was basically a chronic one with an occasional acute or subacute defibrination process associated with further enlargement of the hepatic tumor. These provide sufficient evidence that the intravascular coagulopathy was closely related with the hemangioma in the liver. Neither ligation of a presumed nutritional artery of the hemangioma nor radiation therapy caused any demonstrable reduction in the tumor size.

Time-lapse changes in the concomitant immunity of lymphocytes from different sites of mice isografted with methylcholanthrene-induced tumor.

As a step in the elucidation of the mutual relationship between the degree of cancer progress and the antitumor activity of lymphocytes from different sites in cancer-bearing body, we isografted methylcholanthrene-induced tumor (MC-tumor) subcutaneously on the back of mice. The regional axillary lymph nodes, spleen and distant mesenteric lymph nodes were removed from these animals one, two, three, and four weeks later. We mixed lymphocytes prepared from these lymphatic tissues with primary MC-tumor culture cells and cultured together to estimate antitumor acitivity of lymphocytes from different sites. It has been found that a strong antitumor activity can be seen only in those regional axillary lymph node cells taken out one or two weeks after tumor transplatation and such an activity is weakened by three or four weeks. On the other hand, distant mesenteric lymph node cells one or two weeks after the transplantation have no antitumor activity as yet, while at the terminal cancer stage of four weeks there appears a stronger antitumor activity than that of regional lymph nodes. In the spleen, a strong antitumor activity can be observed in the third week after tumor transplantation, but the activity disappears by the fourth week. These findings support our previous findings in that for the tumor onset after the transplantation the antitumor activity seems to appear first in the regional lymph nodes, and when the tumor grows beyond a certain size, such an activity diminishes while it appears in further distant lymphatic tissues.

A case of chronic pancreatitis with pseudoaneurysm rupturing into a pseudocyst.

A 44-year-old man with alcohol-induced chronic pancreatitis was referred to our institute for evaluation of severe anemia. The hemoglobin was 2.6g/dl. The results of upper gastrointestinal and colonic examination were negative. Computed tomography and ultrasound examination revealed a pseudocyst in the head of the pancreas. A pseudoaneurysm of the anterior superior pancreaticoduodenal artery shown by angiography appeared to have caused gastrointestinal bleeding by rupturing into the pancreatic cyst connected to the main pancreatic duct. A pyrorus-preserving pancreaticoduodenectomy was performed successfully.

Solitary pancreatic metastasis from renal cell carcinoma.

A rare case of resectable solitary pancreatic metastasis from a renal cell carcinoma is reported. The patient was a 57-year-old man who presented with epigastralgia. He had undergone a radical nephrectomy of the right side 30 months previously. The diagnosis of pancreatic metastasis was based on the patient's past history and angiographic demonstration of typical hypervascular tumor staining. Histological examination was confirmatory. The patient was successfully treated by pancreaticoduodenectomy followed by alpha-interferon administration. As of 6 months after surgery, he remains well.

Real-time evaluation of the effectiveness of microwave coagulation therapy for hepatocellular carcinoma using color Doppler imaging.

Percutaneous microwave coagulation therapy (PMCT) is a new technique for the treatment of hepatocellular carcinoma (HCC). However, it is difficult to distinguish those lesions in which necrosis has been induced from the viable residual lesions during the procedure, because the margin of the tumor becomes unclear during PMCT. We determined the area of necrotic lesions during the procedure using color Doppler imaging. PMCT was performed on 10 patients (17 lesions) with recurrent HCC. The electrode of the microwave delivery system was moved around the tumor and the surrounding area until color mosaic images disappeared from the entire area of the tumor. The areas in which necrotic tissue was indicated by color Doppler imaging were later confirmed by other modalities such as angiography or contrast-enhanced computed tomography. This leads us to believe that real-time, effective evaluation of PMCT is possible with color Doppler imaging.

[Clinical evaluation of cefmetazole for the prevention of postoperative wound infections].

The authors treated 415 patients, with injection of 4 g cefmetazole (CMZ) per day after operation of the digestive tract. In these cases, the prevention of postoperative wound infections was investigated and the following results were obtained. Out of 415 cases, 11 cases (2.7%) had postoperative wound infections; 6 cases of which were superficial wound infections and 5 cases deep wound infections. In relation to the degree of infection of the surgical field of them, 10 cases were performed with the contamination by bowel organisms and 1 case was in infected surgical field. Bacteriological examination was carried out. Twenty-four strains of bacteria were isolated and identified. The major bacterial strains identified were 6 strains of S. faecalis, 4 strains of E. cloacae and 4 strains of P. aeruginosa. These organisms were rarely sensitive to CMZ. The results suggest that the organisms causing postoperative wound infections are changing compared with the organisms of previous reports and that the use of CMZ as a postoperative medication is useful in the prevention of wound infections.

[Clinical evaluation of intramuscular imipenem/cilastatin sodium in surgical infections].

A multi-center clinical study was carried out at the first Department of Surgery, Okayama University Medical School and its affiliated institutions to evaluate the efficacy and safety profiles of intramuscular imipenem/cilastatin sodium (IPM/CS) in surgical infections, which were mainly biliary tract infections and peritonitis. The following results were obtained: 1. The efficacy rate was 72.0% in a total of 25 evaluable patients and 81.8% in patients with cholecystitis. 2. The efficacy rates in patients with and without underlying diseases were 70.0% and 73.3%, respectively, and they were 71.4% in patients with mild or moderate infections and 75.0% in patients with severe infections. 3. Bacteriologically, the eradication rate was 100% for Gram-positive bacteria and 62.5% for Gram-negative bacteria, with an overall eradication rate of 78.6%. The eradication rate for monomicrobial infections was 71.4% and that for polymicrobial infections was 100%. 4. Out of 25 patients, one developed diarrhea as a drug-related adverse reaction, and laboratory abnormalities attributable to the treatment were observed in 5 patients. None of them was serious, however. 5. The overall usefulness rate was 60.0%, and the usefulness for cholecystitis (72.7%) was superior to that for cholangitis (33.3%).

[Bacteria isolated from surgical infections and their susceptibilities to antimicrobial agents. Special references to bacteria isolated between April 1997 and March 1998].

The annual multicenter studies on isolated bacteria from infections in general surgery and their antimicrobial susceptibility have been conducted in 19 facilities in Japan since July 1982. This paper describes the results obtained during the period from April 1997 to March 1998. The number of cases investigated as objectives was 215 for one year. A total of 420 strains (170 strains from primary infections and 250 strains from postoperative infections) were isolated from 174 cases (80.9% of total cases). In primary infections, the isolation rate of anaerobic bacteria was higher than in postoperative infections, while in postoperative infections, those of aerobic Gram-positive bacteria and Pseudomonas aeruginosa were higher than in primary infections. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus faecalis was the highest, followed by Staphylococcus aureus, which was frequently isolated from postoperative infections. Among anaerobic Gram-positive bacteria, Peptostreptococcus spp. and Streptococcus spp. were commonly isolated from both types of infections. Among aerobic Gram-negative bacteria, Escherichia coli was most predominantly isolated from primary infections, followed by P. aeruginosa, Klebsiella pneumoniae in this order, and from postoperative infections, P. aeruginosa was most predominantly isolated, followed by E. coli and K. pneumoniae. Among anaerobic Gram-negative bacteria, Bacteroides fragilis group was the majority of isolates from both types of infections. We found neither vancomycin nor arbekacin resistant strains of S. aureus, and found no vancomycin resistant strains of Enterococcus spp. The susceptibility of P. aeruginosa against carbapenems did not decline in the year 1997, while resistance of B. fragilis group against cephems advanced increasingly.

[Bacteria isolated from surgical infections and their susceptibilities to antimicrobial agents. Special references to bacteria isolated between April 1998 and March 1999].

The annual multicenter studies on isolated bacteria from infections in general surgery and their antimicrobial susceptibility have been conducted in Japan since July 1982. This paper describes the results obtained in fiscal 1998 (from April 1998 to March 1999). The number of cases investigated as objectives was 225 for one year. A total of 429 strains (121 strains from primary infections and 308 strains from postoperative infections) were isolated from 183 cases (81.3% of total cases). In primary infections, the isolation rates of anaerobes and Escherichia coli were higher than in postoperative infections, while in postoperative infections, those of Gram-positive aerobes and Pseudomonas aeruginosa were higher than in primary infections. On the whole, among Gram-positive aerobes, the isolation rate of Enterococcus faecalis was the highest, followed by Staphylococcus aureus with high frequency in isolation from postoperative infections. Among Gram-positive anaerobes, Peptostreptococcus spp. and Streptococcus spp. were predominantly isolated. Among Gram-negative aerobes, E. coli, P. aeruginosa, Klebsiella pneumoniae and Enterobacter cloacae were frequently isolated. Among Gram-negative anaerobes, Bacteroides fragilis group was the majority of isolates. In primary infections, the percentage of Gram-negative aerobes has gradually increased since fiscal 1995 or 1996 with these years as the turning point, while those of Gram-positive and Gram-negative anaerobes have gradually declined. In postoperative infections, the percentage of Gram-negative anaerobes has increased continuously since the mid-1980s. The percentage of MRSA among S. aureus rose to 89.7%, which was the highest level since the beginning of this study. The susceptibilities of B. fragilis, which did not show apparent changes, were recognized to have decreased against cephems in fiscal 1998. Among other bacteria in B. fragilis group, development of resistance to cephems has continued on a long-term basis since the mid-1980s. E. coli and K. pneuminiae have obviously not changed in susceptibilities, however, the susceptibilities of isolated strains in fiscal 1998 against high-generation cephems, oxacephems and monobactams have declined. We found neither vancomycin-resistant nor teicoplanin-resistant strains of S. aureus and Enterococcus spp.

[Basic and clinical evaluations of cefmetazole in postoperative wound infections].

The time course of the concentration of cefmetazole (CMZ) in the serum and in skin and intestinal tissues was determined after a single intravenous injection of 2 g of the drug. CMZ moved into them well. Furthermore, 41 patients with postoperative wound infection (superficial in 29 and deep in 12) were treated with CMZ 2-4 g daily. Bacteriological examination of the lesions with simultaneously carried out. As a result, 101 strains of bacteria were isolated and identified. Mixed infection was found in 27 cases (65.9%). Fifteen strains (14.9%) of E. coli, 15 (14.9%) of B. fragilis, 7 (6.9%) of Klebsiella sp. and 7 (6.9%) of Proteus sp., were the main bacteria isolated. Eight cases (19.5%) had mixed infection of E. coli and B. fragilis. The committee (3 members) evaluated CMZ to be effective in 75.6% (31 of 41 cases) and bacteria disappeared in 60.5% (23 of 38 cases). The side effects observed were pyrosis and feeling of gastric malaise in 1 case. The results suggest that CMZ is useful, which exerts an excellent effect on postoperative wound infections.

[Clinical evaluation of a serum immunosuppressive (IS) substance in various diseases].

The IS substance (molecular weight: 52,000, pI: 2.7-3.3) levels in the serum was examined in patients with various diseases. The IS substance levels in patients with gastric, colorectal, biliary-pancreas and esophageal cancer were significantly higher than those in healthy volunteers. The level of IS substance increased in accordance with advance of cancer, showing the highest level in advanced and recurrent cancer patients. In benign disease patients, high levels of IS substance were also observed in the serum of infectious diseases and chronic renal failure. In contrast, patients with liver cirrhosis had a definite low level of IS substance. When the IS substance level was compared with other parameters in cancer patients, a definite correlation was found with immunosuppressive acidic protein and alpha 2 globulin. However, there was no correlation with skin reaction, lymphocyte number, T-cell number, or PHA induced lymphocyte blastgenesis. It is suggested that the IS substance level is a useful indicator to judge the extent of disease before operation and to estimate the clinical course after operation.

[Effect of NK-421 (Bestatin) and Ge-132 on the cytotoxicity of spleen cells obtained from the tumor-bearing mice].

The effect of NK-421(Bestatin) and Ge-132 (an organic germanium compound) on the ADCC and natural killing (NK) activities of the spleen cells of MH-134 tumor-bearing mice were studied. In the tumor-bearing mice, the ADCC activity was enhanced, and NK activity was reduced in accordance with the progress of the tumor. By oral administration of Bestatin at doses of 5, 10 and 50 mg/kg, ADCC activity was potentiated, and at a dose of 10 mg/kg, NK activity was significantly increased. Intraperitoneal administration of Ge-132 at 50 mg/kg potentiated the ADCC activity of tumor-bearing mice. A higher activity was observed in the plastic dish adherent fraction. Ge-132 also potentiated the reduced NK activity of tumor-bearing mice to higher level than normal mice. The elevated activities of ADCC and NK following Bestatin and Ge-132 administration were decreased with anti-Thy-1 antibody and complement; however, the percent reduction was lower compared to that of the control cancer animals. This result indicates that Bestatin and Ge-132 may act on non-T cells and augment ADCC and NK activities.

[Effect of transfusion of blood components on gastric cancer patients--special reference to the incidence of postoperative hepatitis and prognosis].

To evaluate the effect of blood transfusion on incidence of postoperative hepatitis and prognosis of gastric cancer, the data of 493 patients having been operated on curatively in our hospital were divided into two groups: those who received transfusion before the beginning of components transfusion and those who received transfusion after that. The data indicated that the incidences of postoperative hepatitis increased from 3.7% to 5.4% after the beginning of transfusion of blood components, but the 5-year survival rates did not differ significantly. The 5-year survival rates of transfused patients and non-transfused patients were 57%, 84%, respectively (p less than 0.001) and the rates decreased according to the dose of whole blood and/or packed red cells. The same results were obtained when limited to stages I + II, But they were not deteriorated by fresh frozen plasma significantly. The result suggests that it is better to refrain from unnecessary blood transfusion and transfuse whole blood in the case of massive transfusion to decrease the incidence of postoperative hepatitis and more better to transfuse leucocyte-free blood to avoid immunological effect.

[The effect of endoscopical intratumoral injection of OK-432 in gastric carcinoma].

Many BRMs (biological response modifiers) have been used for post-operative immunochemotherapy. And their usefulness were also reported. Nevertheless it is still unknown that which route, how much doses and which timing are the most effective to administer these drugs. We used BRMs intratumorally and preoperatively. To reconfirm the efficacy of intratumoral injection therapy randomized study was performed in gastric carcinoma. Three hundred and ninety-five cases were entered, 199 cases in group A which were treated preoperatively with OK-432 intratumorally and 196 cases in group B which were control, respectively. In the cases which had marked infiltration of lymphoid cells in tumor sites, the two year survival rate of group A was significantly better than that of group B (p less than 0.05). On the study of recurrent forms, the distal lymph node metastasis was markedly decreased in group A. The ratio of metastasis to the distal lymph nodes in group A was 5-10% lesser than that in group B on the each depth of tumor invasion. The ratio of lymph nodes metastasis was almost similar in the each group, but the number of metastatic lymph nodes was significantly reduced in high grade tumor infiltrated cases in group A (p less than 0.005). These results suggest that preoperative endoscopically intratumoral administration of OK-432 suppresses the lymph node metastasis and improves the postoperative survival rate.

[Post-operative suppression of natural killer activity].

The effects of anesthesia and surgical procedures on natural killer (NK) cell activity were studied. The data indicated that splenic lymphocytes taken from mice 1 to 5 days after surgery showed significantly diminished activity of natural killing. When splenic lymphocytes were treated by anti-Thy 1 antibody and complement, NK activity to Lewis lung carcinoma cells was remarkably depressed in normal mice, but was not depressed in laparotomized mice. Peripheral lymphocytes from cancer patients following major surgery also showed depressed NK activity. The suppression was first detected during the operation. In patients undergoing major gastrointestinal surgery, the suppression was at its maximum during first three days and decreased to control levels by the day 7 to 14. Following major thoracic surgery, the suppression continued more longer.