Comparison between pancreatoduodenectomy and hepatopancreatoduodenectomy for bile duct cancer.

BACKGROUND/AIMS: Pancreatoduodenectomy has been accepted as a standard operative procedure for distal bile duct cancer with low operative mortality. However, hepatopancreatoduodenectomy has not been accepted as a standard treatment modality for diffuse bile duct cancer. METHODOLOGY: From December 12, 1992 to December 15, 2000, 37 patients with the diagnosis of extrahepatic bile duct adenocarcinoma (cholangiocarcinoma) underwent pancreatoduodenectomy or hepatopancreatoduodenectomy, at the department of surgery, Ibaraki Prefectural Central Hospital and the Cancer Center. The differences in indications and results of both operative procedures were investigated retrospectively. RESULTS: Thirty-day operative mortality was 0% after either pancreatoduodenectomy or hepatopancreatoduodenectomy. One- to 5-year cumulative survival rates for the 24 patients after pancreatoduodenectomy were 76.3%, 41.5%, 41.5%, 41.5%, 41.5%, respectively. One- to 4-year cumulative survival rates for the 13 patients after hepatopancreatoduodenectomy were 48.0%, 32.0%, 32.0%, 16.0%, respectively. There were no statistically significant differences between cumulative survival rates after pancreatoduodenectomy and hepatopancreatoduodenectomy either in all the patients or in patients with UICC stage IV. CONCLUSIONS: Hepatopancreatoduodenectomy should be tried for patients with diffuse bile duct cancer, because only hepatopancreatoduodenectomy has the possibility of a cure at this time.

Peripancreatic arteries in thin-section multislice helical CT.

BACKGROUND: The normal and pathologic anatomies of the peripancreatic arteries were demonstrated using thin-section multislice computed tomography (CT). METHODS: Triple-phase dynamic CT was performed in 304 consecutive patients without pancreatic pathology and in 22 patients with pancreatic carcinoma. CT angiographies images (2.5-mm collimation, multihelical pitch 3, HQ mode) and a 1.25-mm reconstruction interval were obtained with a GE Lightspeed Qx/i at 25, 40, and 80 s after bolus injection of 130-150 mL of iodinated contrast medium at a rate of 3-5 mL/s. The images were assessed mainly by the manual cine paging method. RESULTS: The anterior and posterior arcades and the dorsal pancreatic artery were frequently visualized. However, small-caliber arteries smaller than 1.5 mm in diameter, such as the pancreaticomagna, caudal pancreatic, and transverse pancreatic arteries, were infrequently visualized. In some cases, the peripancreatic arteries were very useful for differentiating the origin of tumors. CONCLUSION: Multislice helical CT enables the recognition of small peripancreatic arteries, and evaluation of these arteries should be considered when assessing tumors in the pancreaticoduodenal region.

[Visualization of abdominal arteries by super-high-flow venous injection using multidetector helical CT].

The purpose in this study was to compare the ratio of visualization of upper abdominal arteries using MDHCT between the super-high-flow injection method (Group A) and the conventional injection method (Group B). The subjects ects were 200 patients who were randomly divided into Group A (100 patients) and Group B (100 patients). In Group A, visualization of the large arteries, including the CE, SMA, HA and LGA, was possible at a rate exceeding 96%, and that of the small arteries, including the DPA, SPDA, RGA and Cyst A, was more than 79%. Visualization of upper abdominal arteries was markedly improved by the super high flow injection technique.

[Ineffective and recurrent cases of thoracoscopic sympathectomy for hyperhidrosis and intractable pain].

We reported the cases of thoracoscopic sympathectomy, that is, six cases of hyperhidrosis, three of post herpetic neuralgia, and four of reflex sympathetic dystrophy, including recurrent or incompletely resected or ineffective ones. Recently this procedure for hyperhidrosis had been performed frequently because of its effectiveness, less pain, early discharge and cosmetic aspect. For an ineffective case of hyperhidrosis abdominal respiration which emphasized the exhalation and using an upper abdomen decreased the sweating. The balance of autonomic nerve system, toward parasympathetic dominant, was thought to be improved by conscious respiration. The decrease of sweating right after the operation in a case of incomplete resection indicated that intraoperative maneuver could restrict the sympathetic nerve. This procedure for a pain control could be less effective than that for hyperhidrosis, so an adequate preoperative informed consent was thought to be necessary.

[A case of spontaneous hemopneumothorax associated with uncontrolled massive bleeding after inserting thorathic drain].

A 31-year-old man admitted to our hospital complaining of right chest pain. Chest X-ray on admission revealed a collapsed lung and an air fluid line in the right thorax. A chest tube drainage was carried out, but hemorrhagic pleural fluid was drainaged. Forty minutes later, an anemia developed and chest X-ray showed increased massive right pleural collection. Therefore, emergent surgery was performed. An operation under thoracoscopic guidance was converted into thoracotomy because of massive blood clots and fresh bleeding. A bleeding originating from the branch of 1st intercostal artery and a bulla on upper lobes were noted. The artery was coagulated with electrocoutary and ligated using Endo-loop. This artery is not congenital abnormal one but collateral expanded one of which the elastic lamina is thickened. Spontaneous hemopneumothorax is life-threatening, emergent operation should be undergone.

Pancreatoduodenectomy for locally advanced or recurrent colon cancer: report of two cases.

A 66-year-old man, who had ascending colon cancer which invaded the duodenum, pancreas, and superior mesenteric vein, underwent a curative resection including an extended right hemicolectomy, pylorus-preserving pancreatoduodenectomy, and a partial resection of the superior mesenteric vein. The pathological examination revealed adenocarcinoma of the colon, which directly invaded the duodenum and pancreas, thus causing duodenocolic fistula. Tumor infiltration to the superior mesenteric vein was not histologically proven. Two out of 40 lymph nodes were also involved. The patient is still alive and disease-free 37 months after the operation. A 72-year-old man, with a history of surgery two previous times for ascending colon cancer and its recurrence, underwent a third operation including a resection of the former ileocolic anastomosis en bloc by means of a pylorus-preserving pancreatoduodenectomy with a curative intent. The pathological examination revealed adenocarcinoma of the colon, which directly invaded the duodenum and pancreas. Seven out of 31 lymph nodes were also involved. The patient died of recurrence 24 months after the third operation. These two cases demonstrated the usefulness of a resection of the colon en bloc by means of a pancreatoduodenectomy in patients with either locally advanced colon cancer or locally advanced recurrent colon cancer.

[Treatment for advanced colorectal carcinoma with 5-fluorouracil plus low-dose leucovorin].

From July 1992 to May 1996, 16 patients with non-curative postoperative or recurrent colorectal carcinomas were treated with 5-fluorouracil (5-FU) plus leucovorin (LV) systemic chemotherapy. LV was given at a dose of 20 mg/m2/d immediately followed by 5-FU at 370 mg/m2/d. LV was given by rapid intravenous (i.v.) injection and 5-FU by rapid or drip i.v. for 5 consecutive days. Courses were repeated once every 4 weeks for two months and then once every 5 weeks. All patients took 3 or more courses. The toxicity was tolerable, but one patient needed hospitalization because of severe gastro-intestinal toxicity. We observed 3 PR cases, no CR and an overall response rate of 19%. The response duration was 6 to 8 months, averaging 7.3 months, and median survival was 12 months. It was possible to perform this chemotherapy on an outpatient basis, so we think this chemotherapy is superior to in-hospital chemotherapy considering the issue of quality of life. However, the response rate was low and its duration was short. We must investigate chemotherapy further with new and more powerful chemical modulations to increase the response rate and to prolong the response duration.

[Spiral volumetric CT venography of the lower extremities: preliminary report].

Twelve cases, including varicose veins (7), deep venous thrombosis (3), A-V malformation (1) and skin ulcer (1), were examined by three-dimensional CT venography (3D CTV), and comparison was made with conventional ascending venography. In the "double phase method," the first phase scan (40 seconds) of the femoral region was performed in order to rule out deep venous thrombosis, and the second phase scan (30 seconds) of the lower leg was performed to visualize varicose veins. Veins of the thigh and popliteal space were relatively well visualized. It is thought that 3D-CTV is particularly useful for spatially evaluating deep venous thrombosis and varicose veins.

Internal stenting of the hepaticojejunostomy and pancreaticojejunostomy in patients undergoing pancreatoduodenectomy to promote earlier discharge from hospital.

Internal stenting of the hepaticojejunostomy and pancreaticojejunostomy was performed in 11 consecutive patients undergoing pancreatoduodenectomy between July 1992, and July 1994, to promote earlier discharge from hospital. Although minor leakage of the pancreaticojejunostomy occurred in 4 patients, this resolved within a short period and all 11 patients were able to be discharged by the 29th postoperative day in good health and without any intubation. Follow-up abdominal X-ray and computed tomography (CT) scans proved that all 22 of the stenting tubes had spontaneously fallen out by the 176th postoperative day. No complication related to the stenting tubes occurred in any of our patients.

Application of three-dimensional spiral computed tomographic angiography prior to hepatectomy for hepatocellular carcinoma.

A newly developed method of spiral computed tomography (CT) angiography was employed for 19 consecutive hepatocellular carcinoma (HCC) patients who underwent hepatectomy. Fine images of the intrahepatic vascular structure, portal venous branches and hepatic veins, and HCC nodules were obtained in 16 patients. A more accurate and easier understanding of the relationship between the intrahepatic vascular structure and the HCC nodules was provided by this spiral CT angiography compared with any other imaging modality.

Pulmonary artery reconstruction using a great saphenous vein autograft in the treatment of bronchogenic cancer.

Sleeve resection of the pulmonary artery, followed by reconstruction with or without bronchoplasty, for bronchogenic carcinoma located at a major lobar orifice has been reported as an alternative to pneumonectomy in patients with poor respiratory functional reserve. We describe herein what is, to our knowledge, the first report of a successful pulmonary arterial reconstruction using a saphenous vein autograft. This operation was performed in a 63-year-old man with poor pulmonary functional reserve who was diagnosed as having a large bronchogenic cancer in the left lower lobe of the lung, located close to the pulmonary hilum. First, a left lower lobectomy was performed with segmental resection of the pulmonary artery, from the basal artery to the lingular artery, after which pulmonary arterial continuity was reconstructed using a saphenous vein autograft. The patient had an uneventful recovery and remains well without any sign of recurrence 4 months after his operation.

[A case of recurrent mediastinal goiter (oxyphilic cell carcinoma)].

A case of recurrent mediastinal goiter (oxyphilic cell carcinoma) in a 66-year-old female was reported. 19 years ago, the patient submitted to a right-hemithyroidectomy for the oxyphilic cell adenoma. Since two months, her dyspnea gradually aggravated. On admission, abnormal mass of right upper mediastinum was shown by chest X-ray. CT scan and MRI showed a 8 cm sized right upper mediastinal tumor with tracheal compression.

[Endoscopic visualization of luminal organ and great vessels with three dimensional CT scanner. A new trial using volumetric CT].

Thirty cases examined by three dimensions CT scanner (3DCT) were reported. The observation of inner view using 3DCT were performed in 12 large vessels with vascular disorder, 10 pulmonary bronchus with lung cancer and 8 common bile ducts involved obstructive disease. In order to visualize interface of the lumen, a new software which was devekioed by HITACHI MEDICO Inc. and us was brought in. In all cases but one the inner view of the luminal organ was clearly demonstrated as 3D images and it was possible to judge some changes of luminal interface involved by the diseases. The 3DCT endoscopic image might be useful as a new endoscopic technique without fiberscopy.

[Endoscopic surgery of airway lesions by Nd-YAG laser treatment].

Between April 1980 and November 1990, we treated 212 cases of airway lesion using an Nd-YAG laser via the fiberoptic bronchoscope. The Nd-YAG laser power output was usually 40 W (20-60 W) delivered in 2 sec. shots. The cases consisted of 98 primary lung cancer, 12 primary tracheal cancer, 53 metastatic airway lesion, 7 benign tumor, and 42 cicatricial and granulomatous lesions. The therapeutic effects of Nd-YAG laser treatment were evaluated based on alleviation of dyspnea, widening of airway, and curative vaporization for therapeutic purposes. Effectiveness was observed in 180 of a total of 212 cases (84.9%). Out of 75 emergency cases in which a lifesaving procedure was performed to widen the airway, effective results were obtained in 70 (93.3%) with dramatic improvement in condition. It was also effective in 90 of 109 cases (82.6%) in which the procedure was performed for staged (palliative) widening of airway. In 55 cases of advanced lung cancer (Stage III or IV, mainly non-small cell cancer) in which palliative widening procedure was performed, one year survival was 44%. In 13 of 18 cases (72.2%) in which the procedure was performed for curative vaporization of invasive cancer, successful results were obtained. In 7 cases of benign tumor in which vaporization was performed as a radical curative procedure, no recurrence was observed in any cases. In 53 cases of metastatic airway lesion, effective results were obtained 48 (90.6%). The primary lesions of these cases consisted of 14 cases of esophageal cancer, 9 cases of lung cancer, 7 cases of colo-rectal cancer, 7 cases of thyroid cancer, and 16 others.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of chest wall reconstruction with scapular flap and rib autotransplantation for recurrent esophageal cancer].

Subtotal esophagectomy was carried out for esophageal cancer in a 64-year-old male patient. The postoperative stage was a1, n2, stage III. From around 10 months after surgery, a recurrent tumor of first size was recognized at the right anterior lateral thoracic wall, corresponding to the site of the thoracotomy wound, and the tumor involved the right 4th 5th ribs and the subcutaneous soft tissue including the pectoralis major and latissimus dorsi muscles. Total layer chest wall resection including 3rd to 6th ribs, with the tumor was performed. In order to reconstruct the cutaneous soft tissue, a scapular skin flap with vascular pedicle of the circumflex scapular artery and vein was made. Moreover, for the purpose of reinforcing the osseous thoracic wall, a free autogenous rib was transplanted; namely, the 7th rib was cut in half lengthwise and then fixed like a bridge at the center of the defective site of the thoracic wall. Finally, the region was covered with the scapular skin flap for the chest wall reconstruction. After the surgery, supplemental ventilation was not necessary. Although fracture of the transplanted rib was recognized at month 2, the thorax was stable, even immediately after the surgery. Therefore, this method is considered to be useful for reconstruction after total layer chest wall resection.

The present status of bronchoscopic Nd:YAG laser.

In Japan, the first bronchoscopic Nd:YAG laser applied clinically was performed in our institute 10 years ago, and based on this decade of experience, the indications, effectiveness, and limitations were studied. Between 1980 and 1989, a total of 202 cases were treated by Nd:YAG laser in our institute. Among them, 94 (46.5%) cases were primary lung cancers, 10 (5.0%) cases were primary tracheal malignancies, 56 (27.7%) cases were metastatic tracheal tumors, 6 (3.0%) cases were benign tracheal tumors, and 36 (17.8%) cases were nontumorous tracheal lesions. The indications for Nd:YAG laser therapy were defined as emergency widening of airway, curative treatment, reduction of tumor size, nontumorous benign lesions, and hemostasis. The desired therapeutic effects were obtained in 55/58 (94.8%) for emergency airway widening, 22/27 (81.5%) for curative treatment, 69/88 (78.4%) for reduction of tumor size, and 48/68 (70.6%) for nontumorous benign lesions. While performing Nd:YAG laser treatment, some limitations, such as poor residual pulmonary function, tumor size, tumor depth, cartilage structure, granulation, and stricture length, were encountered. Since bronchoscopic Nd:YAG laser treatment has become a well-established therapeutic modality for tracheobroncheal lesions, areas to be addressed in the future are the training of bronchoscopic laser therapists and research on the extension of applications. To increase the range of clinical applications, it is hoped that makers of laser systems will provide tunable wavelength machines at reduced cost.

Change in a complex translocation involving band 7q34 and 9p- in a case of T-cell lymphoblastic lymphoma.

The authors report a case of T-cell type non-Hodgkin's lymphoma (NHL) in which neoplastic cells possessed a three-way translocation involving chromosomal bands 3q21, 7q34, and 22q11, as well as partial monosomy of the short arm of chromosome 9. In the literature, most reported cases of 7q32-q36 abnormalities had T-cell type leukemia/lymphoma and were younger than 20 years. Two NHL cases, including the current case, were diagnosed as having lymphoblastic lymphoma with a leukemic transformation. The neoplastic cells of the reported cases commonly showed CD2 (E-rosette receptors) and CD38. All 17 patients but three manifested a mediastinal mass at diagnosis and seven had central nervous system lesions or pleural infiltration. Furthermore, five of the 19 reported cases also showed 9p- change.

[A case report of mediastinal malignant lymphoma with long survival following combination chemotherapy using adriamycin, vincristine and cyclophosphamide].

Mediastinal B-cell malignant lymphoma of a 22-year-old female was successfully treated by combination chemotherapy including Adriamycin, Vincristine and Cyclophosphamide. She suffered from dyspnea and axillary tumor in September 1984. Roentgenological examination revealed a large anterior mediastinal tumor. Biopsy of the axillary tumor yielded a diagnosis of metastatic undifferentiated carcinoma from thymus by hematoxylin and eosin. Radiotherapy and chemotherapy including CDDP and ACNU resulted in a symptom-free period of only 2 months. Superior vena cava syndrome and massive pleural effusion recurred. Salvage chemotherapy including Adriamycin, Vincristine and Cyclophosphamide resulted in rapid therapeutic effect. Six courses of chemotherapy were administered, and she is alive and well 4 years after the first salvage chemotherapy. A definitive diagnosis of B-cell lymphoma was made after review of biopsy specimens using immunohistochemical procedures. To select adequate treatment for mediastinal malignant lymphoma, reliable diagnostic procedures including immunohistochemistry are needed. Intensive chemotherapy with appropriate drugs may obtain good response even in advanced cases, such as this.