Combination of preoperative embolization of the right portal vein and hepatic artery prior to major hepatectomy in high-risk patients: a preliminary report.

BACKGROUND/AIMS: Preoperative transhepatic portal vein embolization may not always be sufficient to achieve the desired changes in contralateral hepatic volume and function. The beneficial role of additional transcatheter arterial embolization performed after inadequate response to preoperative transhepatic portal vein embolization is described. METHODOLOGY: Four patients underwent both preoperative transhepatic portal vein embolization and transcatheter arterial embolization, and 6 control patients underwent preoperative transhepatic portal vein embolization only. Changes in right liver lobe volume fraction, residual left lobe volume fraction, and prediction score (low-risk, < 45; borderline, 45-55; high-risk > 55); were evaluated. RESULTS: 1) The change in right liver lobe volume after both preoperative transhepatic portal vein embolization and transcatheter arterial embolization (volume after/before) was 0.75 times that of the original level whereas after preoperative transhepatic portal vein embolization, they were only 0.81 times that of the original level. 2) The change in residual left liver volume after both preoperative transhepatic portal vein embolization and transcatheter arterial embolization (volume after/before) was 1.40 times that of the original level whereas after preoperative transhepatic portal vein embolization they were only 1.30 times than the original level. The changes in left liver volume after preoperative transhepatic portal vein embolization/transcatheter arterial embolization was more favorable than those after preoperative transhepatic portal vein embolization only. 3) The change in prediction score after both preoperative transhepatic portal vein embolization and transcatheter arterial embolization (after/before) was 0.81 times that of the original level. All prediction score in high-risk patients recovered to the borderline or safety zone. Change after preoperative transhepatic portal vein embolization only (before/after) was 0.87 times that of the original level. 4) All 4 patients who underwent both preoperative transhepatic portal vein embolization and transcatheter arterial embolization received right hepatic lobectomy successfully and returned to their normal life style. CONCLUSIONS: Preoperative occlusion of right hepatic inflow vessels increased the volume and function of the contralateral lobe where high-risk patients recovered to the borderline zone for major hepatic resection.

Limited pancreatectomy: significance of postoperative maintenance of pancreatic exocrine function.

This study attempted to clarify whether limited pancreatectomy (duodenum-preserving total pancreatic head resection [DPTPHR], or medial pancreatectomy [MP], maintain pancreatic exocrine function more than conventional pancreaticoduodenectomy (Whipple) or pylorus-preserving pancreaticoduodenectomy (PPPD). A total of 125 patients (18 with Whipple, 71 with PPPD, 13 with DPTPHR, and 23 with MP) were studied. Fecal chymotrypsin and p-type amylase, and pancreatic function diagnostant (PFD) tests were used for evaluation. There were no differences in preoperative background. Pancreatic function was seen to be significantly lower after surgery than before surgery in patients who underwent the Whipple procedure and PPPD (P < 0.05), but there was no difference between pre- and postoperative pancreatic function in patients who underwent DPTPHR and MP. Postoperative pancreatic function was shown to be significantly worse in Whipple procedure and PPPD patients than in those with DPTPHR and MP (P < 0.05). Patients who underwent the Whipple procedure and PPPD showed significantly lower pancreatic function than patients who underwent DPTPHR and MP (P < 0.05). There was no difference in pancreatic function between patients who underwent DPTPHR and those with MP. DPTPHR and MP, both of which preserve the entire duodenum, maintain pancreatic function more than the Whipple procedure and PPPD.

The effects of omeprazole, a proton pump inhibitor, on early gastric stagnation after a pylorus-preserving pancreaticoduodenectomy: results of a randomized study.

BACKGROUND/AIMS: To determine the effects of Omeprazole, a proton pump inhibitor (PPI), on gastric stasis following a pylorus-preserving pancreatico-duodenectomy (PPPD) by means of a randomized trial of PPPD patients. METHODOLOGY: Forty-two PPPD patients were randomly divided into two groups: Group 1 (n=24) received a PPI through a jejunal tube after PPPD, whereas Group 2 (n=18), serving as controls, received a saline solution through a jejunal tube and no medication after a PPPD. The daily volume and total acidity of the gastric juice, aspirated via nasogastric tube, were measured each day for 7 days following PPPD. RESULTS: In Group 1 the mean daily aspirated volume of gastric juice was 160.2 ml, and the mean maximum volume was 222.8 ml on the first postoperative day. In Group 2, six patients were withdrawn from this study for therapy on the third or fourth postoperative day due to gastric bleeding and/or a large amount of excreted gastric juice (in excess of 2,000 ml). The mean daily aspirated volume of gastric juice in the remaining Group 2 patients was 787.4 ml, and the mean maximum volume was 1,039 ml on the third postoperative day. Gastric secretion was significantly lower in Group 1 (p<0.05). Further, the total acidity of the gastric juice was significantly lower in Group 1 than in Group 2 for each of the 7 postoperative days (p<0.05). CONCLUSIONS: These results indicate that postoperative administration of a PPI significantly suppresses the volume and acidity of the gastric juice after PPPD.

Joint fluid from patients with failed total hip arthroplasty stimulates pit formation by mouse osteoclasts on dentin slices.

Periprosthetic bone resorption has been implicated in the failure of total joint arthroplasty. Osteolysis is reported to be associated with bone resorption induced by bone-resorbing cytokines, which are released from macrophages and fibroblasts in periprosthetic tissues after stimulation by wear debris generated in the joint cavity. Recent reports have suggested the concept of the effective joint space, which includes all periprosthetic regions that are accessible to joint fluid and wear debris. In this study, we examined the levels of interleukin-6 (IL-6), soluble IL-6 receptor (sIL-6R), and tartrate-resistant acid phosphatase (TRAP) in joint fluid after failed total hip arthroplasty (THA) with osteolysis and investigated whether the joint fluid could activate osteoclastic bone resorption using unfractionated mouse bone cells cultured on dentin slices. Histochemical analysis showed the presence of more TRAP-positive cells in synovial capsules from failed THA patients when compared with osteoarthritis (OA) patients (controls). The levels of IL-6, sIL-6R, and TRAP in joint fluid from failed THA patients were significantly higher than in OA patients. Mouse osteoclasts cultured on dentin slices with joint fluid from failed THA patients with osteolysis produced a significant increase of pit area, whereas cells cultured with joint fluid from OA patients did not. Interestingly, osteoclastic bone resorption on dentin slices was significantly correlated with TRAP activity in joint fluid (p < 0.0001). These results suggest that joint fluid containing bone-resorbing cytokines is produced by synovial capsules in failed THA patients with osteolysis and may activate osteoclasts around the prosthesis in combination with those produced by interface tissues, thus contributing to periprosthetic bone resorption.

An introduction to mucin-producing tumors of the pancreas: why they deserve more attention.

BACKGROUND/AIMS: Mucin-producing tumors of the pancreas are clinically characterized by dilatation of the major pancreatic duct due to pooled mucin, and by dilatation of the orifice of the duodenal papilla. The concept of mucin-producing tumors of the pancreas was proposed in 1982, but has undergone revision since then. METHODOLOGY: The present paper reviews the history, classification, and description of mucin-producing tumors of the pancreas. Problems relating to this type of tumor are also discussed. RESULTS: The clinical concept of mucin-producing tumors of the pancreas has affected studies of the pancreatic diseases in many areas. First, when recognition of pancreatic cancer with a relatively good prognosis commenced, this concept led to awareness of the necessity for a detailed examination of the pancreatic duct epitheliums in cases of suspected pancreatic carcinoma. Second, the concept made it easier to diagnose carcinoma in situ. Third, new classifications of cystic lesions of the pancreas were initiated. Fourth, a molecular biological view of the onset of pancreatic cancer was developed. Pathologically, this type of tumor is characterized by papillary growth of the epitheliums within the pancreatic duct, and it has been regarded as having a good prognosis. The term mucin-producing tumors of the pancreas now includes: intraductal papillary tumors which are non-invasive carcinomas or carcinoma in situ; duct-ectatic tumors, or mucinous cystic tumors; and, invasive carcinomas, derived from the former types. CONCLUSIONS: The definition of "mucin-producing tumor of the pancreas" has been undergoing revision. In the past, it has referred to pancreatic tumors with a good prognosis. It is now time to consider a more detailed classification.

Pancreatic duct patency after pancreaticogastrostomy: long-term follow-up study.

BACKGROUND/AIMS: To clarify whether the pancreatic duct remains patent during long-term follow-up of patients after pancreaticogastrostomy. In a previous study of pancreaticogastrostomy with post-operative follow up for 3 years after surgery, we found that the orifice of the pancreatic duct was difficult to detect in some patients because of swelling of the gastric mucosa. Previous studies have not examined pancreatic duct patency during long-term follow-up. METHODOLOGY: Between July 1985 and August 1989, 20 patients underwent a pylorus-preserving pancreaticoduodenectomy with reconstruction by pancreaticogastrostomy. Five of these patients were followed up post-operatively for more than 9 years to determine the patency of the pancreatic duct. All pancreatic anastomoses were performed by the telescopic method. RESULTS: All 5 patients were female, with a mean age of 65.4 years (range: 54-75). Median post-operative follow-up was 10.8 years (range: 9-12). The indications for surgery were carcinoma of the ampulla of Vater in 4 patients and chronic pancreatitis in 1 patient. Pancreatic duct patency was confirmed in 4 patients by gastroscopy and pancreatography. However, the anastomotic orifice could not be detected in the remaining patient because of complete coverage by the gastric mucosa. In this patient, pancreatic exocrine and endocrine function deteriorated with dilation of the distal pancreatic duct. The patient underwent a second operation involving dissociation of the pancreatico-gastric anastomosis and resection of about 1 cm of the fibrous, proximal portion of the pancreas. Reconstruction was performed with a Roux-en-Y pancreaticojejunostomy and a mucosa-to-mucosa anastomosis. CONCLUSIONS: Although pancreaticogastrostomy has been applied as a safe and straightforward method for reconstruction after pancreaticoduodenectomy, anastomotic stenosis is a potential late complication of this approach.

[A case of tuberculous arthritis of shoulder].

A rara case of tuberculous arthritis of right shoulder was reported. Plain X ray and CT showed bone destruction in humerus and glenoid process and soft tissue swelling with calcification was also demonstrated. T2 weighted images showed extension of abscess clearly. And extension to bone marrow was showed on CT and T1 weighted MR images.