Acute Infectious Purpura Fulminans Complicated by Bacterial Translocation after Rectal Cancer Surgery: A Case Report.

The patient was a man in his 80s who had undergone laparoscopic anterior resection for rectal cancer. Bowel obstruction occurred on the third postoperative day but improved with a decompression tube by the fifth postoperative day. A high fever (in the 38 °C range) was also observed. Blood culture tests detected two sets of the gram-negative bacilli Klebsiella aerogenes within 24 h of collection. On the seventh postoperative day, the patient subsequently went into septic shock with disseminated intravascular coagulation (DIC). On the eighth postoperative day, the fingertips and toes became black, and the palms and dorsal surfaces of both feet were dark purple due to peripheral circulatory failure. This suggested acute infectious purpura associated with sepsis (acute infectious purpura fulminans (AIPF)). Intensive care was provided; however, the necrosis of both middle fingers worsened, both middle fingers were gangrenous, and the patient died on the thirtieth postoperative day. AIPF is rarely reported, especially in early-onset cases after elective surgery. We encountered a rare complication of bacterial translocation from postoperative bowel obstruction, leading to AIPF.

Mid-term outcomes of intracorporeal versus extracorporeal anastomosis after laparoscopic colectomy: a propensity score-matched cohort study from a single institution.

PURPOSE: There is still insufficient discussion of the mid- to long-term safety of the intracorporeal anastomosis (IA) method of reconstruction after laparoscopic colectomy (LAC) for colon cancer. The present study clarified the postoperative mid-term results of IA based on recurrence and the incidence of incision hernia. METHODS: This single-institution observational retrospective study included 268 patients with colon cancer who underwent IA or extracorporeal anastomosis (EA) after LAC at our institution between 2018 and 2021. The mid-term results of the IA group were compared with those of the EA group using a propensity score matching method. RESULTS: The median follow-up periods were 36 and 25 months in the EA and IA groups, respectively (p < 0.0001). In this matched cohort study, the recurrence-free survival (RFS) rates were comparable between the IA and EA groups (each group, n = 72; 3-year RFS: IA, 92.1%; EA, 88.2%; hazard ratio, 0.78; 95% confidence interval, 0.25-2.40; p = 0.66). The cumulative incisional hernia rates were 9.8% and 9.9% (p = 0.99) for the IA and EA groups, respectively. CONCLUSION: The safety of IA after LAC was demonstrated in this study, as IA after LAC showed good mid-term results, including with regard to the rates of recurrence and incisional hernia.

[A Case of Advanced Esophagogastric Junction Adenocarcinoma with Enlarged Lymph Node Metastases of the Middle Mediastinum and Intraperitoneal That Exhibited pCR by Preoperative SOX Therapy].

A 79-year-old man was diagnosed with esophagogastric junction adenocarcinoma, cT3N3M0, cStage Ⅲ, including enlarged lymph node metastases(Bulky N)in the middle mediastinum and intraperitoneal. A total of 2 cycles of S-1 plus oxaliplatin(SOX)was administered. After neoadjuvant chemotherapy, the primary tumor and enlarged lymph nodes had greatly decreased in size. Subsequently, thoracoscopic subtotal esophagectomy and reconstruction with a gastric tube were performed. Histopathological examinations showed no residual cancer cells in the primary lesion and dissected lymph nodes (pathological complete response). Preoperative chemotherapy containing SOX could be a useful treatment strategy for patients with esophagogastric junction adenocarcinoma with enlarged lymph node metastasis.

Long-standing diabetes mellitus increases concomitant pancreatic cancer risk in patients with intraductal papillary mucinous neoplasms.

BACKGROUND: When monitoring patients with an intraductal papillary mucinous neoplasm (IPMN), it is important to consider both IPMN-derived carcinoma and concomitant ductal adenocarcinoma (PDAC). The latter is thought to have a poorer prognosis. We retrospectively analyzed the risk factors for concomitant PDAC in IPMN. METHODS: In total, 547 patients with pancreatic cysts, including IPMNs inappropriate for surgery on initial diagnosis, encountered from April 2005 to June 2019, were reviewed. We performed surveillance by imaging examination once or twice a year. RESULTS: Five IPMNs with high-grade dysplasia and one IPMN associated with invasive carcinoma were encountered. In comparison, 14 concomitant PDACs were encountered. The prognosis was very poor for concomitant PDACs. All 14 PDAC patients had IPMNs. In patients with IPMNs, long-standing diabetes mellitus was the only significant risk factor for concomitant PDAC in both univariate and multivariate analyses (P < 0.001 and P < 0.01, respectively). Furthermore, patients with IPMNs and diabetes mellitus had a high frequency of concomitant PDACs (9.5%, 9/95) in a median 48-month surveillance period. CONCLUSIONS: When monitoring IPMNs, the development of not only IPMN-derived carcinomas but also concomitant PDACs should be considered. During this period, it may be prudent to concentrate on patients with other risk factors for PDAC, such as long-standing diabetes mellitus.

[Retrospective Analysis of Adjuvant Chemotherapy for Elderly Patients with Stage â ¢ Colorectal Cancer].

OBJECTIVE: To investigate the efficacy and toxicity of adjuvant chemotherapy(AC)in elderly patients with Stage Ⅲ colorectal cancer(CRC). METHODS: We performed a single-institutional retrospective analysis of 84 patients aged≥75 years with Stage Ⅲ CRC who underwent curative resection from August 2009 to February 2018. RESULTS: Thirty-seven(44.0%) patients received AC. Eleven(29.7%)patients required dose reduction at the start of AC. Twenty-three(62.2%)patients accomplished AC, and 13(35.1%)needed dose reduction during AC. Although toxicities of Grade 3 or higher occurred in 56.8% of patients, they were controllable. The 3-year recurrence-free survival rate was significantly better in the AC group than in the non-AC group(70.3% versus 50.5%, respectively; p=0.011). The prognosis tended to be worse in the group that started AC with dose reduction than in the group with the normal dose. CONCLUSION: AC is effective and well tolerated in elderly patients with Stage Ⅲ CRC. When reducing the initial dose, the need for dose reduction should be carefully considered.

[Usefulness of Nutritional Evaluation in Adjuvant Chemotherapy for Colorectal Cancer in Older Patients].

OBJECTIVE: To clarify the usefulness of Onodera's prognostic nutritional index(OPNI)in adjuvant chemotherapy(AC)for older patients with colorectal cancer. MATERIALS AND METHODS: This study included 39 patients aged over 70 years who underwent AC for colorectal cancer from August 2009 to February 2018. We evaluated the association of OPNI with AC toxicities and prognosis. RESULTS: OPNI was an independent predictor of toxicities of Grade 3 or higher(OR: 0.18, 95%CI: 0.043-0.75, p=0.019). The 3-year recurrence-free survival rate was significantly better in the higher OPNI group than in the lower OPNI group(89.9% and 66.7%, respectively; HR: 0.19, 95%CI: 0.04-0.92, p=0.038). There was a positive correlation with Spearman's rank correlation coefficient of 0.66 in OPNI before and after AC(p<0.001). CONCLUSION: OPNI could be one of the valuable predictors of AC toxicities and the prognosis. There was a high correlation between OPNI before and after AC. These findings suggest the importance of early nutritional support for patients with lower OPNI.

A case of intraductal tubulopapillary neoplasm of the pancreas in a branch duct: a rare case report and literature review.

BACKGROUND: Intraductal tubulopapillary neoplasm (ITPN) of the pancreas is a new disease concept defined by the World Health Organization in 2010. ITPN progresses with tubulopapillary growth in the pancreatic duct and is known to have a fair prognosis. Localization in the main pancreatic duct (MPD) is one characteristic. There are few case reports of ITPN in a branch of the pancreatic duct (BD). CASE PRESENTATION: We encountered a case of ITPN localized in BD. An 85-year-old man was followed after colonic surgery for rectal carcinoma. An abdominal computed tomography scan revealed a cystic mass in the pancreatic head and further examination was done. A T2 weighted intension picture in magnetic resonance imaging showed a 20 mm cystic lesion with an internal mass of 15 mm. Duodenal papilla were slightly open and endoscopic retrograde pancreatography revealed mild and diffuse dilatation of the main pancreatic duct and mucin in the MPD. In consideration with the image examinations, we diagnosed the tumor as an intraductal papillary mucinous neoplasm with carcinoma because of its large mural nodule (> 10 mm in size) in a cyst. Consequently, a pancreaticoduodenectomy was performed. Macroscopically, a white solid tumor sized 2.5 × 1.8 × 1.0 was identified in the head of the pancreas. The cut surface of the resected pancreas showed a side-branch type intraductal tumor with tubulopapillary architecture without mucin secretion. Immunohistochemical staining was positive for MUC1, and negative for MUC2 and MUC5AC. The final diagnosis was determined to be pancreatic ITPN from BD. At the time of this report (48 months post-surgery), the patient remains disease-free without evidence of recurrence. CONCLUSION: ITPNs localized in BD are rare and diagnosis prior to surgery is difficult. In our case, the shape was round, not papillary, and with little fluid. These characteristics are different from a branch duct type IPMN and can be a clue to suspect ITPN in BD.

[Rapid Growing Anterior Mediastinal Leiomyosarcoma with Pericardial Infiltration:Report of a Case].

Primary mediastinal leiomyosarcoma is extremely rare, and few reports in the literature have described the clinical features of this malignancy. We report a case of a small anterior mediastinal leiomyosarcoma that showed rapid growth within a short period. An 85-year-old woman showed a small anterior mediastinal tumor on chest computed tomography (CT), three months prior to presentation. Contrast-enhanced chest CT revealed rapid tumor growth, and positron emission tomography/CT revealed significant 18-fluorodeoxyglucose uptake, suggestive of malignancy. Thoracoscopic tumor resection was performed via the left thoracic approach. In addition to the tumor and surrounding anterior mediastinal tissue, we resected an area of pericardial infiltration. The tumor was diagnosed as a primary mediastinal leiomyosarcoma based on histopathological and immunohistochemical findings.

Full Laparoscopic Anatomical Segment 8 Resection for Hepatocellular Carcinoma Using the Glissonian Approach with Indocyanine Green Dye Fluorescence.

BACKGROUND: Anatomical resections have been reported to achieve better long-term outcomes compared with partial resections for the treatment of hepatocellular carcinoma (HCC). Despite this, laparoscopic anatomical resections are very challenging operations, especially when approaching the posterosuperior segments of the liver (IVa, VII, and VIII). We report a full laparoscopic anatomical segment 8 resection focusing on the technical aspects of the Glissonian approach. METHODS: A routine follow-up CT scan of an 80-year-old women affected by hepatitis C-related liver cirrhosis showed a 3-cm HCC in segment 8. Three-dimensional reconstruction was performed to evaluate the liver anatomy, the relationship of the lesion with major vessels, and the borders of segment 8. A true anatomical segmentectomy was performed by using selective occlusion of segment's 8 Glissonian pedicle, which was identified from the liver hilum. Indocyanine green (ICG) dye demarcation was used as a guidance during parenchymal transection.1-4 RESULTS: Operative time was 420 min, and blood loss was 261 mL. The patient had an uneventful postoperative course and was discharged home after 8 days. CONCLUSIONS: Full laparoscopic anatomical segment 8 resection is a technically challenging operation. The use of the Glissonian approach and the aid of ICG dye could be of help, but advanced laparoscopic skills are necessary to complete such a difficult procedure safely.5-13.

New Diagnostic Criteria for the Localization of Insulinomas with the Selective Arterial Calcium Injection Test: Decision Tree Analysis.

PURPOSE: To explore optimal diagnostic criteria for localizing insulinomas with the selective arterial calcium injection (SACI) test using decision tree analysis. MATERIALS AND METHODS: A retrospective study included 86 vessels of 18 patients (5 men, 13 women; mean age 67 y; range, 49-73 y) with insulinomas who underwent SACI test between June 2007 and May 2016. Of 27 insulinomas, 7 were found in the head, 13 in the body, and 7 in the tail of the pancreas. Two patients had multiple tumors. To identify optimal diagnostic criteria, decision tree analysis was performed, and sensitivity, specificity, and accuracy of the conventional and the proposed new diagnostic criteria (plasma insulin concentration after calcium injection [ICpost] > 2.0 × plasma insulin concentration before calcium injection [ICpre]) were compared. RESULTS: The proposed new diagnostic criteria for insulinoma obtained by decision tree analysis were (i) ICpost > 2.7 × ICpre and maximum insulin concentration > 60.3 µIU/mL or (ii) ICpost > 2.7 × ICpre and maximum insulin concentration < 60.3 µIU/mL with ICpre being ≥ 7.5 µIU/mL. Sensitivity, specificity, and accuracy of the new criteria for the SACI test were 100%, 91.4%, and 94.2; sensitivity, specificity, and accuracy of conventional criteria were 100%, 69.0%, and 79.1%. CONCLUSIONS: New diagnostic criteria for localization of insulinomas with the SACI test yielded higher diagnostic performance than conventional criteria.

Diffusion-weighted MR imaging of pancreatic cancer and inflammation: Prognostic significance of pancreatic inflammation in pancreatic cancer patients.

BACKGROUND: Pancreatic cancer often accompanies chronic obstructive pancreatitis (COP) due to obstruction of the main pancreatic duct, and the inflammatory environment may enhance cancer progression. The purpose of this study is to evaluate COP using the apparent diffusion coefficient (ADC) value measured by diffusion-weighted MR imaging (DWI), and to assess its prognostic significance in pancreatic cancer. METHODS: Twenty-eight patients (16 men, 12 women; mean age 67.1 years) with pancreatic cancers who underwent DWI followed by curative surgery were evaluated. The ADC value of pancreatic parenchyma upstream to the tumor (upstream pancreas) was measured and compared with the upstream pancreatic duct dilatation to assess whether DWI could reflect COP. The ADC values of tumor and upstream portion were compared with overall survival (OS) using Cox regression and Kaplan-Meier analysis. RESULTS: The ADC value of upstream pancreas was significantly lower in patients with greater dilated pancreatic duct than those with less (P = 0.03). In univariate Cox regression analysis, the ADC value of upstream pancreas showed a significant association with OS (P = 0.01), but that of tumor did not (P = 0.06). In Kaplan-Meier analysis, patients with lower ADC value of upstream pancreas (<1.36 × 10(-3) mm(2)/s) were significantly associated with poor OS (P = 0.0006). In multivariate analysis, the ADC value of upstream pancreas was identified as an independent prognostic factor (P = 0.01; hazards ratio, 0.05; 95% CI, 0.004-0.59). CONCLUSIONS: The ADC value of upstream pancreas was an independent prognostic factor for OS in pancreatic cancer patients. Inflammatory environment may play an important role in pancreatic cancer progression.

Preoperative Coil Embolization in Patients With a Replaced Hepatic Artery Scheduled for Pancreatectomy With Splanchnic Artery Resection Helps to Prevent Ischemic Organ Injury.

OBJECTIVE: The aim of this study was to evaluate the prevention of liver ischemic injury by preoperative coil embolization in patients with a replaced hepatic artery scheduled for pancreatectomy with splanchnic artery resection. METHODS: Between July 2009 and May 2012, 4 patients with replaced hepatic artery underwent pancreatectomy plus splanchnic artery resection. The replaced right hepatic artery was preoperatively embolized in 2 patients. In the other 2 patients, the common hepatic artery was embolized preoperatively. We evaluated the complications encountered in the perioperative period. RESULTS: There were no embolization-related complications. Although 2 patients presented with small liver infarcts, the aspartate aminotransferase and alanine aminotransferase levels did not exceed 1000 IU/L in any of the patients, and none experienced severe liver injury. CONCLUSIONS: Coil embolization before pancreatectomy with splanchnic artery resection in patients with a replaced hepatic artery may help to prevent severe ischemic liver injury in the perioperative period.

Is it possible to define early distal cholangiocarcinoma?

PURPOSE: The feasibility of defining early cholangiocarcinoma has not been adequately evaluated. The surgical outcomes of patients who had undergone pancreatoduodenectomy (PD) for pathological T1 (pT1) distal cholangiocarcinoma (DCC) were evaluated to determine whether it is possible to define early DCC. METHODS: The clinicopathological data of 18 patients with pT1 DCC who had undergone PD were reviewed retrospectively. Depth of fibromuscular (fm) layer invasion was divided into two categories: fm1 and fm2 (without adventitia fascia invasion and with adventitia fascia invasion). Comparative analyses were performed according to the depth of invasion. RESULTS: Disease-specific survival rates of patients with five mucosal tumors and 13 fm-invasive tumors were 80 and 61.9 % at 5 years and 80 and 41.2 % at 10 years, respectively. There was no significant difference in disease-specific survival rates between the two groups (P = 0.244). Disease-specific survival rates of patients with 7 fm1-invasive tumors and 6 fm2-invasive tumors were 85.7 and 40 % at 5 years and 85.7 and 0 % at 10 years. A significant difference in disease-specific survival rates was observed between mucosal tumors and fm2-invasive tumors (P = 0.043), and disease-specific survival rates of mucosal tumors and fm1-invasive tumors were similar (P = 0.968). CONCLUSIONS: Defining early DCC as carcinoma confined to the fm of the bile duct might be inappropriate; early DCC should be limited to the mucosal carcinoma.

[Anomalous Systemic Arterialization of a Normal Basal Lung Segment with Aneurysm of the Aberrant Artery].

A 40-year-old woman was noted to have clubbing of the nails during an outpatient service for smoking cessation. Chest computed tomography showed an aneurysm of an aberrant artery running from the descending aorta to the left lower lobe. Hence, we diagnosed anomalous systemic arterialization of the lung. The proximal part of the aberrant artery measured 13 mm in diameter;moreover, it had developed an aneurysm(17 mm in diameter) in the lung parenchyma. The aberrant artery was ligated with a covering material (absorbable felt) and cut via a small access thoracotomy by a cardiovascular surgeon;subsequently, left lower lobectomy was performed. Pathological examination revealed significant atherosclerosis in the aberrant artery, demonstrating its severe fragility. To apply appropriate safety procedures and approaches are recommended when treating an aberrant artery to the lung, especially in the presence of an aneurysm.

Radiation dose reduction at coronary artery calcium scoring by using a low tube current technique and hybrid iterative reconstruction.

PURPOSE: The aim of this study was to compare the accuracy of coronary artery calcium scoring (CACS) on cardiac computed tomographic images using hybrid iterative reconstruction (hIR) and a low tube current as well as on images acquired with a filtered back projection (FBP) algorithm and a normal tube current. SUBJECTS AND METHODS: Patients (N = 77) with suspected coronary artery disease were subjected to 2 CACS evaluations based on their Agatston, volume, and mass scores. One CACS evaluation was performed on images obtained with a 364-mA tube current and reconstructed with FBP; the other was performed on images obtained with a 73-mA tube current and reconstructed with hIR at iDose4. All scans were performed with the prospective electrocardiogram-triggered method using a 256-slice computed tomographic scanner (Brilliance iCT; Philips). We assessed agreement between calcium scores obtained with FBP and with IR using the percentage difference and Bland-Altman analysis. RESULTS: The effective radiation doses for CACS at 80 mA s with FBP and at 16 mA s with IR were 1.20 and 0.24 mSv, respectively (k = 0.014). The mean Agatston, volume, and mass scores at 80 mA s with FBP as well as at 16 mA s with IR were 390.7, 146.5, and 63.2 as well as 377.7, 142.5, and 62.2, respectively. The percentage difference between FBP and hIR for the Agatston, volume, and mass score was 20.7%, 20.7%, and 27.1%, respectively. Bland-Altman analysis showed that there was no systemic bias. CONCLUSIONS: The radiation dose for CACS can be reduced at a low tube current and hIR without affecting the calcium score.

Transarterial therapy of hepatocellular carcinoma fed by the right renal capsular artery.

PURPOSE: To evaluate the characteristics of hepatocellular carcinomas (HCCs) fed by the right renal capsular artery and to assess the tumor response and complications in patients treated with transarterial therapy via the renal capsular arteries with or without other extrahepatic arteries and/or intrahepatic arteries. MATERIALS AND METHODS: Between March 2006 and May 2012, 24 lesions in 19 patients were treated by transcatheter arterial chemoembolization (23 sessions), transcatheter arterial embolization (two sessions), or transcatheter arterial infusion (one session), with HCCs fed by the right renal capsular artery with or without intrahepatic arteries and/or other collateral arteries. Other intrahepatic lesions were concurrently treated if needed. RESULTS: Tumor size ranged from 10 mm to 107 mm (mean, 30.5 mm). Of the 24 tumors, 12 were located in segment VI, 10 in segment VII, one in the posterior segment, and one in the anterior segment after posterior segment resection. Severe complication occurred in four patients: liver abscess (n = 2), pleural effusion (n = 1), and duodenal ulcer (n = 1). Pleural effusion might be related to chemoembolization via the right renal capsular artery. A complete response was obtained in six sessions and a partial response in eight; 10 sessions were associated with stable disease and two with progressive disease. CONCLUSIONS: Precise renal capsular artery knowledge would facilitate successful and safe transarterial therapy for HCCs fed by the renal capsular arteries.

Experience with chemotherapy for postoperative metastases of adenosquamous carcinoma of the esophagogastric junction and pathological study of its development.

We report here a case of postoperative recurrent adenosquamous carcinoma (ASC) of the esophagogastric junction (EGJ) treated with S-1 therapy. A 79-year-old woman was diagnosed with carcinoma of the EGJ. Thoracoscopic subtotal esophagectomy was performed, and pathological examination revealed advanced ASC with lymph node metastasis. Five months after surgery, multiple lung metastases and multiple lymph node metastases were observed, and the patient was treated with S-1 monotherapy, which showed partial response and may be effective for advanced ASC of the EGJ. On the other hand, immunohistological analysis of the tumors showed a relatively wide range of areas that could differentiate into both adenocarcinoma and squamous cell carcinoma, suggesting that tumor cells with multidifferentiation potential, or at least the ability to differentiate into both adeno-epithelial and squamous epithelial cells, were the likely source of the tumors.

Profilin 2 isoform expression is associated with lung metastasis of colorectal cancer according to a comprehensive gene expression study using a mouse model.

Lung metastasis is the second most common type of metastasis in colorectal cancer. Specific treatments for lung metastasis have not been developed since the underlying mechanisms are poorly understood. The present study aimed to elucidate the molecular basis of lung metastasis in colorectal cancer. In a mouse model, cell lines that were highly metastatic to the lungs were established by injecting colorectal cancer cells through the tail vein and removing them from the lungs. Differential gene expression comparing the transfected cells with their parental cells was investigated using DNA microarrays. The results were functionally interpreted using gene enrichment analysis and validated using reverse transcription-quantitative PCR (RT-qPCR). The isoforms of the identified genes were examined by melting curve analysis. The present study established colorectal cancer cell lines that were highly metastatic to the lungs. DNA microarray experiments revealed that genes (N-cadherin, VE-cadherin, Six4, Akt and VCAM1) involved in motility, proliferation and adhesion were upregulated, and genes (tissue inhibitor of metalloproteinase-3 and PAX6) with tumor-suppressive functions were downregulated in metastatic cells. Profilin 2 (PFN2) expression was upregulated in multiple metastatic cell lines using RT-qPCR. Two PFN2 isoforms were overexpressed in metastatic cells. In vitro and in vivo models were established and genes associated with lung metastasis were identified to overcome the heterogeneity of the disease. Overall, aberrant PFN2 expression is unreported in lung metastasis in colorectal cancer. In the present study, two PFN2 isoforms with differential tissue distribution were upregulated in metastatic cells, suggesting that they promote lung metastasis in colorectal cancer.

A multi-institutional study designed by members of Tokyo Guidelines (TG) Core Meeting to elucidate the clinical characteristics and pathogenesis of acute cholangitis after bilioenteric anastomosis and biliary stent insertion with a focus on biliary obstruction: Role of transient hepatic attenuation difference (THAD) and pneumobilia in improving TG diagnostic performance.

BACKGROUND/PURPOSE: The aim of this study was to clarify the clinical characteristics of acute cholangitis (AC) after bilioenteric anastomosis and stent-related AC in a multi-institutional retrospective study, and validate the TG18 diagnostic performance for various type of cholangitis. METHODS: We retrospectively reviewed 1079 AC patients during 2020, at 16 Tokyo Guidelines 18 (TG 18) Core Meeting institutions. Of these, the post-biliary reconstruction associated AC (PBR-AC), stent-associated AC (S-AC) and common AC (C-AC) were 228, 307, and 544, respectively. The characteristics of each AC were compared, and the TG18 diagnostic performance of each was evaluated. RESULTS: The PBR-AC group showed significantly milder biliary stasis compared to the C-AC group. Using TG18 criteria, definitive diagnosis rate in the PBR-AC group was significantly lower than that in the C-AC group (59.6% vs. 79.6%, p < .001) because of significantly lower prevalence of TG 18 imaging findings and milder bile stasis. In the S-AC group, the bile stasis was also milder, but definitive-diagnostic rate was significantly higher (95.1%) compared to the C-AC group. The incidence of transient hepatic attenuation difference (THAD) and pneumobilia were more frequent in PBR-AC than that in C-AC. The definitive-diagnostic rate of PBR-AC (59.6%-78.1%) and total cohort (79.6%-85.3%) were significantly improved when newly adding these items to TG18 diagnostic imaging findings. CONCLUSIONS: The diagnostic rate of PBR-AC using TG18 is low, but adding THAD and pneumobilia to TG imaging criteria may improve TG diagnostic performance.

Long-term surgical outcomes of patients with type 1 autoimmune pancreatitis.

BACKGROUND: Although pancreatectomy has sometimes been performed for patients with autoimmune pancreatitis (AIP) presenting atypical radiologic findings under the diagnosis of pancreatobiliary malignancy, the long-term surgical outcome of these patients had not yet been fully elucidated. METHODS: The long-term surgical outcomes of 13 patients with pathologically diagnosed type 1 AIP with immunohistochemical staining for immunoglobulin G4 (IgG4) were retrospectively compared with those of 34 patients with conventional chronic pancreatitis to evaluate the residual pancreatic function. RESULTS: A definite relapse of AIP in terms of the clinical manifestations and diagnostic imaging was not found in any of the patients, although one patient experienced an attack of acute pancreatitis caused by pancreatic stones, and stricture of the hepaticojejunostomy occurred in one patient. The overall body weight decreased significantly more in patients with AIP than in patients with conventional chronic pancreatitis (p < 0.05); however, there was no difference in the preoperative nondiabetic patients. Refractory diarrhea occurred in only one patient with AIP. The cumulative new-onset rates of diabetes mellitus of the ten patients with AIP and 24 patients with conventional chronic pancreatitis at 5 years after the surgery were 32.5 and 26.1 %, respectively (p = 0.70). CONCLUSIONS: Careful long-term follow-up is needed for patients undergoing pancreatectomy for type 1 AIP because remnant pancreatic function can deteriorate as severely as that of patients who undergo pancreatectomy for conventional chronic pancreatitis. In the present series, however, there were few definite manifestations indicating relapse or the persistent existence of AIP.