Extreme discrepancy between macroscopic diagnosis and pathological findings of gallbladder cancer treated by hepatopancreatoduodenectomy.

Diagnosis of gallbladder cancer in terms of invasion depth and spread is an important factor in determining cumulative survival after surgical treatment. However, diagnostic methods available at present occasionally fail to judge staging correctly. We report a case of gallbladder cancer which showed extreme discrepancy between the preoperative macroscopic and imaging diagnosis (positive direct invasion to the liver and invasion to the bile duct and duodenum through the serosal layer; S3, Hinf3, Binf2, and stage IV by the Japanese Society of Biliary Surgery classification) and the pathological findings (limited in vasion within the subserosal layer; ss, hinf0. binf0, and stage II). This discrepancy allowed us to perform curative treatment by hepatopancreatoduodenectomy, including extended right lobectomy of the liver, external bile duct resection, resection of the mesocolon, and lymph node dissection. Surgeons should aim for curability of advanced gallbladder cancer by radical resection until accurate methods for the preoperative diagnosis of cancer spread are available, because the clinical picture may be modified by inflammatory changes.

Treatment of ruptured hepatocellular carcinoma.

BACKGROUND: The problem of whether surgical or conservative treatment is indicated for ruptured hepatocellular carcinoma (HCC) has not been analyzed from the viewpoint of long-term development of hepatitis viral infection from liver fibrosis to liver cirrhosis. Although transcatheter arterial embolization (TAE) for hemostasis followed by two-stage hepatectomy has been established as the best treatment for ruptured HCC, there still remain difficulties in the treatment of some patients. METHODS: Twelve patients with ruptured HCC who were surgically or conservatively treated were retrospectively analyzed in terms of modality of treatment, liver function, extension of HCC, complications, survival rate, and cause of death. RESULTS: Tumor rupture can occur either in the early phase or in the terminal phase during the development from liver fibrosis to liver cirrhosis, while tumor rupture occurs at the advanced stage in terms of HCC extension. TAE for emergent hemostasis or prevention of re-bleeding was performed in ten patients, while TAE was contraindicated in one patient and emergent laparotomy for hemostasis was performed in one patient. In four patients, elective extended surgical resection was performed, because liver function was evaluated as clinical stage 1 according to the General rules for the clinical and pathological study of primary liver cancer of the Liver Cancer Study Group of Japan. In seven patients, conservative or medical treatment was selected, because liver function was evaluated as poor. The surgically treated group, who could tolerate extensive operation, survived longer than the conservatively treated group. CONCLUSIONS: While TAE remains the best method to employ for hemostasis, it still has limitations. Hence, we should be mindful of other possible modalities for hemostasis and their outcomes. Rupture of HCC at an early phase in the development of liver fibrosis is a good indication for elective surgical treatment and should be distinguished from rupture in the terminal phase of liver cirrhosis, which should be treated conservatively. Although elective surgical treatment can be performed in selected patients, tumor size and location of HCC, in addition to liver function, should be taken into consideration.

Severe complications of mediastinal pancreatic pseudocyst: report of esophagobronchial fistula and hemothorax.

We report two patients with alcoholic pancreatic pseudocyst which communicated to the mediastinal space through the aortic hiatus, in one patient resulting in hypotensive shock due to hemothorax, and in the other, resulting in esophagobronchial fistula via the mediastinal cyst. The first patient was successfully treated by radical resection of the pancreatic body and tail, and the spleen, with an ultrasonic scalpel, although inflammatory changes caused by pancreatitis were so prominent that the splenic vein was occluded. The second patient could not be treated surgically, because the superior mesenteric vein had been occluded by chronic pancreatitis; he died of respiratory failure and sepsis due to aspiration pneumonia, despite receiving medical treatment.

Extrahepatic large hepatocellular carcinoma with peritoneal dissemination: multimodal treatment, including four surgical operations.

We report a patient with extrahepatically growing large hepatocellular carcinoma (HCC) associated with disseminated intraabdominal tumor and spontaneous tumor bleeding who was treated with four operations, transcatheter arterial embolization, systemic chemotherapy, and hyperthermia. It took 12 months for the multimodal treatment to normalize the alpha-fetoprotein (AFP) level, and remission continued for 6 months. We performed the fourth surgical treatment for a recurrent abdominal tumor involving the small intestine and mesentery, but the patient died 26 months after the first admission. Multimodal treatment, including repeat surgical treatments, for such advanced HCC should be encouraged, to prolong life and to maintain quality of life.

Usefulness of three-dimensional CT cholangiography for patients prior to laparoscopic cholecystectomy.

PURPOSE: The aim of this study was to demonstrate three-dimensional biliary anatomy by using spiral CT scanning for patients prior to laparoscopic cholecystectomy. MATERIALS AND METHODS: We studied 22 patients (11 men, 11 women; mean age, 60 years) with preoperative imaging. All patients had normal serum bilirubin levels. Either 50 ml (in 10 cases) or 100 ml (in 12 cases) of meglumine iotroxate was infused intravenously over 30 minutes. Spiral CT scanning was started immediately after the infusion was finished. Volumetric data through the entire biliary tracts were obtained during one breath-hold. The data were reconstructed by using a maximum intensity projection algorithm and three-dimensional shaded surface rendering. RESULTS: In all patients, the anatomical relationship between the cystic duct and the common bile duct was clearly depicted, including one with junctional anomaly. The intrahepatic biliary ducts and the confluence of the hepatic ducts were displayed from all angles. The third or higher intrahepatic branches were delineated in 11 of the 12 (92%) patients with the use of 100 ml of the cholangiographic agent and in seven of the 10 (70%) with 50 ml. CONCLUSION: Three-dimensional CT cholangiography was able to provide adequate information about precise biliary anatomy.

Intussusception: the role of general anesthesia during hydrostatic barium reduction.

MATERIALS AND METHODS: A total of 74 patients with intussusception were divided into two groups: 43 cases in 39 patients between April 1974 and June 1988 were treated under general anesthesia, and 39 cases in 35 patients between July 1988 and January 1994 were treated without it. We compared the success rates of barium reduction of intussusception in the two groups and used Fisher's exact probability test to assess whether they differed significantly. RESULTS: The overall success rates with general anesthesia and without general anesthesia were 91% (39/43) and 95% (37/39), respectively. The use of general anesthesia did not significantly affect the success rate of barium reduction (p > 0.3). CONCLUSION: The use of general anesthesia for hydrostatic barium reduction of intussusception did not improve the success rate of this procedure. Therefore we recommend that, in view of its associated disadvantages, general anesthesia should not be used during this procedure.

Peliosis of the spleen: splenic rupture with intraperitoneal hemorrhage.

Peliosis is a rare disease that is characterized by multiple blood-filled cystic spaces. We report the computed tomographic findings of splenic rupture secondary to splenic peliosis in a patient receiving anabolic steroids for aplastic anemia.

Various manifestations of early and minimally advanced gastric cancer in gastrointestinal series (GIS).

Preoperative gastrointestinal series (GIS) have been used to assess the precise localization and extent of early and minimally advanced gastric cancers, which are sometimes difficult to define en face by endoscopy. The purpose of this study was to relate various GIS manifestations of gastric cancer with the pathological condition. We reviewed 99 gastric cancer cases (107 lesions), which were treated between 1992 and 1995, in which the lesions were depicted by GIS assisted by a nasogastric tube. The pathological conditions were determined from the resected specimens. Differences in anatomic location and in some morphological characteristics contribute to differences in histological classification. We conclude that lesion depiction by GIS assisted by nasogastric tube reflects the cancer's pathological characteristics, including histological type, malignant cycle, and modification by desmoplastic reaction.

Presacral epidermal cyst found in an adult male with a high CEA content: report of an unusual case.

A 63-year-old Japanese man presented with constipation, having noticed flat stools for several years. Digital examination of the rectum, followed by barium enema, colono-fiberscopy, computed tomography (CT), and magnetic resonance imaging (MRI) revealed an oval mass located between the retrorectal and presacral space without any mucosal lesion. This mass had narrowed the rectal lumen by compressing the rectum anteriorly. Although the plasma levels of the tumor markers were within the normal range, those of the tumor contents were elevated with a carcinoembryonic antigen (CEA) of 118 ng/mL, while the alpha-fetoprotein (AFP) value was 1 ng/mL. The tumor was completely extirpated through an abdominal incision, and there has been no evidence of recurrence thus far. Histological examination showed that the tumor wall was made of keratinized stratified squamous epithelium without any cutaneous adnexal structure, and hence it was diagnosed as an epidermal cyst. CEA was identified in these benign epithelial cells by immunoperoxidase staining using a monoclonal antibody. To the best of our knowledge, there have been only four other cases with a presacral epidermal cyst documented in the Japanese literature, all of whom were female. Our patient is the first reported case of an adult male with a presacral epidermal cyst.

Intrapleural adaptive immunotherapy for breast cancer patients with cytologically-confirmed malignant pleural effusions: an analysis of 67 patients in Kyoto and Shiga Prefecture, Japan.

Sixty-seven breast cancer patients with cytologically-confirmed malignant pleural effusion, who required intrapleural treatment, were analyzed retrospectively. The patients received their first thoracentesis between 1980 and 1990. Among them, 29 patients received intrapleural administration of OK-432, a streptococcal preparation, followed by the transfer of autologous pleural effusion lymphocytes cultured with interleukin-2. Other intrapleural treatments consisted of OK-432 alone (12 patients), chemotherapeutic agents alone (n = 9), a combination of OK-432 and chemotherapy (n = 16), or others (n = 1). Twenty-six of the 29 patients given OK-432 plus cultured effusion lymphocytes responded, while only 15 of the 38 patients who received other treatments did (p < 0.01). Median survival time and 5-year survival rate of patients who received OK-432 and cultured lymphocytes was 12 months and 36%, while those of the patients who received other treatments was 3 months and 0%, a significant (p < 0.001) difference in survival. Multivariate analysis using Cox's proportional hazard model revealed that the treatment (adoptive immunotherapy) was the most significant (p < 0.005) factor to prolong the survival of the patients among several prognostic factors. Thus, OK-432 and adoptive immunotherapy is a promising therapy that should be further evaluated in a prospective study.

Metallic expanding biliary stents in malignant obstruction. Cases with stent in stent.

We reviewed a total of 13 stent (Gianturco-Rosch biliary Z-stent) placements in 11 patients with biliary obstruction due to malignancy and report the cases treated with the stent-in-stent technique for treatment of stent occlusion due to tumor ingrowth. Causes of biliary obstruction included cholangiocarcinoma (four cases), hepatic hilar metastasis of gastrointestinal carcinoma (five cases), and pancreatic carcinoma (two cases). After transient percutaneous transhepatic biliary drainage (PTBD), the stents were successfully inserted by transhepatic route in all patients without any serious complication that needed further surgical intervention. Almost all patients were freed from the external PTBD tube about a week after stent placement and discharged from the hospital with improvement in quality of life as well as normal serum bilirubin levels. The technical advantages of stent placement include ease of insertion and the ability to drain both right and left biliary systems from a single transhepatic route by arranging the stents in a variety of configurations. Furthermore, it provides a second chance of stent placement when the previous stent has been occluded by tumor ingrowth.

[Intrapleural treatment of breast cancer patients with pleural effusions: an analysis of 13 institutes in Kyoto and Shiga Prefectures. Kyoto and Shiga Breast Cancer Study Group].

Sixty-seven breast cancer patients with malignant pleural effusions underwent their first thoracentesis between 1980 and 1990 at 13 institutes in Kyoto and Shiga Prefectures. They received various intracavitary treatments including OK-432 and cultured effusion lymphocytes (n = 29, group A), OK-432 alone (n = 12), chemotherapeutic agents alone (n = 9), OK-432 and chemotherapy (n = 16) or other (n = 1, lentinan and tetracycline) therapy. Response rate and median survival time were 90%, 12 months for group A, respectively and 40% and 3 months for other treatments (group B, n = 38), resulting in significant differences. Multivariate analysis using Cox's proportional hazard model showed that the immunotherapy using cultured lymphocytes was the most important factor prolonging survival among several significant prognostic factors such as concomitant liver metastasis, disease-free period and laterality of effusion.

[Study on 27 surgical cases of hypertrophic pyloric stenosis at Kyoto City Hospital].

Twenty-seven patients of hypertrophic pyloric stenosis operated on at our hospital between 1977 and 1991 were reviewed. The patients consisted of 22 boys and 5 girls, with males accounting for 81%. Seventeen of the 27 patients were the first children of their mothers. Vomiting was first noted between 10 and 58 days after birth with a mean of 26.5 days, and neonatal onset was observed in 67% of all patients. The body weight decreased after the onset in 17 patients, including 1 in which it decreased below the birth weight. Hypochloremia was the most frequent preoperative electrolyte imbalance, being observed in 41% of all patients. Alkalosis was noted in 17 of the 22 patients in which arterial blood gas analysis could be performed. The olive was palpated preoperatively in 24 (89%) of the 27 patients. The body weight increased in all patients after operation, and the mean daily increase was 26.7 g. The mean period of hospitalization after operation was relatively short at 8.3 days. Postoperative vomiting was observed in 16 patients (59%), with its mean duration being 26 days. All patients showed normal growth after operation, and no postoperative complications were noted.

[Single-daily-dose treatment of ceftriaxone for biliary tract infections and bacterial counts in bile].

To evaluate the effects of ceftriaxone (CTRX) administered once daily, the biliary concentration of CTRX and daily changes in the bacterial count in bile from an indwelling T-tube were measured concomitantly. The effects on prophylaxis of postoperative infections after biliary tract surgery were also examined mainly due to clinical symptoms. The biliary CTRX levels increased rapidly and were sustained as high as 92.5-219 micrograms/ml in all patients even 24 hours after 2 g of CTRX was infused intravenously once daily. Five of 7 patients whose bile samples were positive for bacteria showed high CTRX levels in bile and almost no bacteria present after treatment. CTRX-sensitive bacteria eliminated 1 or 2 hours after the administration in response to the increase of biliary CTRX levels. The changes in bacteria count of bile may be closely related to CTRX antibiotic activity. As an antibiotic prophylaxis, other 18 patients with biliary diseases received intravenous infusion of 2 g of CTRX once daily for 5-7 days (mean 5.9 days). Thus, once-daily dose treatment of CTRX 2 g may have antibiotic effects on biliary infection and postoperative prophylaxis of biliary infections and it is indicated that the prolonged biliary levels of CTRX are essential for its efficacy.

[Chemotherapy in biliary tract infections (XXX). Special reference to the concentration of micronomicin in human gallbladder tissues and bile].

In this study, 120 mg of micronomicin (MCR) was given to 15 cases intended for cholecystectomy intramuscularly by a single injection or 5 consecutive injections (in the evening of day -2, morning and evening of day -1, morning of day 0, and 1 hour before operation) or intravenously by 1-hour drip infusion, and levels of MCR in serum, B bile and gallbladder tissues were determined by means of HPLC and bioassay. The serum level of MCR 30 minutes after consecutive injections (8 cases) was 11.86 +/- 1.90 micrograms/ml, significantly higher than that after the single injection, 7.08 +/- 0.93 micrograms/ml. The highest bile level of MCR after consecutive injections was 10.0 micrograms/ml. The average level in 4 detectable cases, 6.33 +/- 2.06 micrograms/ml, came up to 50% of the serum level and was higher than that after the single injection, 3.53 +/- 1.39 micrograms/ml. The gallbladder tissue level of MCR after consecutive injections was 4.5 micrograms/g at the highest and 2.51 +/- 0.73 micrograms/g on the average in 5 detectable cases. This was equivalent to 20% of the serum level and higher than that after the single injection, 1.63 +/- 0.26 micrograms/g. The MIC of MCR could be determined against 8 of 10 strains detected in B bile. Against E. coli and K. pneumoniae, main causal bacteria of bile duct infections, it was as low as 0.39 to 0.78 micrograms/ml. Levels of MCR in bile and gallbladder tissues determined in this study exceeded by far the above MIC. From these results, it can be expected that clinical administration of MCR at 2 doses of 120 mg daily for 3 days or more will give rise to a sufficiently antibacterial effect against Gram-negative bacilli.