Randomized clinical trial of duct-to-mucosa versus invagination pancreaticojejunostomy after pancreatoduodenectomy.

BACKGROUND: The postoperative pancreatic fistula (POPF) rate for duct-to-mucosa and invagination anastomosis after pancreatoduodenectomy is still debated. The aim of this RCT was to investigate the POPF rate for duct-to-mucosa versus invagination pancreaticojejunostomy. METHODS: Patients were stratified by pancreatic texture and diameter of the main pancreatic duct and randomized to the duct-to-mucosa or invagination group. The primary endpoint was the rate of clinically relevant POPF (defined as grade B or C). Secondary endpoints were suture material cost for pancreaticojejunostomy, drain insertion duration and duration of postoperative hospital stay. RESULTS: Some 120 patients undergoing pancreatoduodenectomy were included following consent. Clinically relevant POPF developed in six of 59 patients (10 per cent) in the invagination group and in 14 of 61 patients (23 per cent) in the duct-to-mucosa group (P = 0·077). Duration of drain insertion (6 versus 7 days respectively; P = 0·027) and postoperative hospital stay (19 versus 24 days; P = 0·015) were shorter in the invagination group. Subgroup analysis for 61 patients with a soft pancreas revealed a lower rate of clinically relevant POPF in the invagination group (10 per cent versus 42 per cent in the duct-to-mucosa group; P = 0·010). Among 20 patients with a clinically relevant POPF, the six patients in the invagination group had a shorter duration of drain insertion (38·5 days versus 49 days for 14 patients in the duct-to-mucosa group; P = 0·028) and postoperative hospital stay (42 versus 54·5 days respectively; P = 0·028). CONCLUSION: This study did not demonstrate a superiority of invagination over duct-to-mucosa pancreaticojejunostomy in the risk of POPF. However, in high-risk patients with a soft pancreas, invagination may reduce the risk of clinically relevant POPF compared with duct-to-mucosa. Registration number: UMIN000005890 (http://www.umin.ac.jp).

[A case of essential thrombocythemia with clonal evolution in the terminal phase].

This 50-year-old male was admitted to the hospital on April 1983 with complaints of severe chest pain attacks 2 weeks previously. Laboratory data: On admission the blood findings were Hb 14.3 Gm/dl of blood, RBC 4.70 million/mm3, WBC 11,600/mm3 and a platelet count of 1.1 million/mm3. ECG showed elevation of ST-T in V1 to V4. Serum LDH and CPK levels were high. He was diagnosed as acute myocardial infarction with thrombocythemia. Three days after admission he abruptly fell into a semicomatose state and left hemiplesia. Head computed tomography showed a large, low-density lesion in the right mid-cerebral artery area, and we also diagnosed cerebral infarction. He was given nimustine (ACNU) 100 mg/week three times as remission induction therapy. For maintenance chemotherapy, at first we administered mitobronitol (DBM) 150 mg/day then changed to intermittent administration of ACNU 100 mg. On September 1991, the patient was admitted to the hospital with progressive anemia and uncontrollable thrombocythemia. Bone marrow chromosome analysis revealed aneuploidy. The patient received interferon alpha 3 million unit/day. The thrombocythemia could be controlled but his general condition deteriorated. On April 1992, he died of interstitial pneumonia.

Amyloidomas in the cerebellopontine angle and jugular foramen. Case report.

The 47-year-old man reported here showed large encapsulated masses in the left cerebellopontine angle and 6 years later in the enlarged left jugular foramen. Histologically, the tumors demonstrated a large deposit of amyloid composed of immunoglobulin light chain-derived proteins (AL). There was no evidence of chronic inflammatory or infectious processes or immunoglobulin abnormalities.

Immunohistochemical study of fibronectin in hemangioblastomas and hemangiopericytomas.

Eight hemangioblastomas and two hemangiopericytomas were studied using indirect immunoperoxidase stains for fibronectin (FN) and glial fibrillary acidic protein (GFAP) in formalin-fixed, paraffin-embedded surgical specimens. Stromal cells in hemangioblastomas were GFAP-negative and showed variable FN expression, while GFAP-positive cells were FN-negative, thus suggesting that the stromal cells are not derived from astrocytes. Hemangiopericytoma cells were poorly to intermediately FN-positive. The origin of stromal cells is discussed in the light of their fine structure and the immunohistochemical stains with other cell markers.

Membrane structures of human oligodendroglioma.

Plasma membrane particles of four human oligodendrogliomas were distributed at random, and their average number per micronm2 plasma membrane was 1090+/-233 on face A and 230+/-46 on face B. Gap junction was occasionally visible, usually small in size and composed of a polygonal aggregate of several subunits: isodiametric particles, about 70-80 A in diameter, on face A and pits, about 30-40 A in diameter, on face B. Tight junction in two oligodendrogliomas was characterized by a meshwork of circular or ramifying crests on face A and complementary furrows on face B. It was often continuous in distribution, consisting of 5 or more strands. In addition, many particulate structures, occasionally fibrillar ones, of ridge materials were often visible in the bottoms of furrows, and a few particles were scatteredly found on the tops of crests. The ridge materials, if added together on crests and furrows, were linearly continuous in some case and discontinuous in other.