A retrospective study of the effect of fibrinogen levels during fresh frozen plasma transfusion in patients with traumatic brain injury.

BACKGROUND: The association between traumatic brain injury (TBI) and coagulopathy is well established. While coagulopathy prophylaxis in TBI involves replenishing coagulation factors with fresh frozen plasma (FFP), its effectiveness is controversial. We investigated the relationship between plasma fibrinogen concentration 3 h after initiating FFP transfusion and outcomes and evaluated the correlation with D-dimer levels at admission. METHODS: We retrospectively examined data from 380 patients with severe isolated TBI with blood samples collected a maximum of 1 h following injury. Plasma fibrinogen and D-dimer concentrations were obtained at admission, and plasma fibrinogen concentration was again assessed 3-4 h following injury. The patients were divided into two groups based on whether or not they received FFP transfusion. Patients were also divided into subgroups according their fibrinogen level: ≥ 150 mg/dL (high-fibrinogen subgroup) or < 150 mg/dL (low-fibrinogen subgroup) 3 h after injury. Demographic, clinical, radiological and laboratory data were compared between these subgroups. RESULTS: Glasgow Outcome Scale (GOS) scores at discharge and 3 months after injury were significantly lower in the FFP transfusion group than in the FFP non-transfusion group. Among patients who received FFP, GOS scores at discharge and 3 months after injury were significantly higher in the high-fibrinogen subgroup than in the low-fibrinogen subgroup. Elevated admission D-dimer predicted subsequent fibrinogen decrease. CONCLUSIONS: In FFP transfusion, fibrinogen level ≥ 150 mg/dL 3 h after injury was associated with better outcomes in TBI patients. Assessing the admission D-dimer and tracking the fibrinogen are crucial for optimal coagulopathy prophylaxis in TBI patients.

[Two Cases of Long-Term Control of Advanced Gastric Cancer Treated with>35 Cycles of Low-Dose Nab-Paclitaxel].

Nanoparticle albumin-bound paclitaxel(nab-PTX)is effective as second-line chemotherapy for advanced gastric cancer. Long-term administration is generally impossible because of peripheral sensory neuropathy. However, we report 2 cases that were treated with>35 cycles of nab-PTX with dose reduction to control disease progression, which appears to be the highest number cycles so far reported. Case 1 was a male patient in his 70s, with distant lymph node metastases and an advanced primary lesion(tub2). He received 6 cycles S-1/CDDP and achieved a partial response; however, the treatment was changed to second-line chemotherapy with nab-PTX because of adverse effects; the dose of nab-PTX was reduced by 60% every 3 weeks. At the time of writing, 36 cycles have been administered and disease control has been maintained, with Grade 2 peripheral sensory neuropathy. Case 2 was another male patient in his 70s, who underwent total gastrectomy for gastric cancer(mucinous adenocarcinoma). Virchow metastasis was detected 6months after surgery. He received 1 cycle S-1/CDDP and achieved a partial response; however, treatment was changed to second-line chemotherapy with nab-PTX because of adverse effects; the dose of nab-PTX was reduced by 60% every 3 weeks. At the time of writing, 41 cycles have been administered and disease control has been maintained, with Grade 2 peripheral sensory neuropathy.

[A Case of Large-Cell Neuroendocrine Carcinoma of the Stomach with Multiple Liver Metastases That Show Complete Response to Multidisciplinary Therapy].

A 64-year-old man was diagnosed with advanced gastric cancer based on an endoscopic examination in June 2009; histological findings indicated poorly differentiated adenocarcinoma.Computed tomography revealed multiple liver metastases and bulky lymph node metastases of LN#7.The multiple liver metastases of the gastric cancer were not considered to be candidates for surgical resection, and S-1/CDDP chemotherapy was initiated in July 2009. After 6 courses of this regimen, liver and lymph node metastases showed partial response(PR), but the gastric tumor showed progressive disease(PD).Therefore, we switched this regimen to bi-weekly CPT-11/CDDP in March 2010. However, because the gastric tumor had increased in size and presented with bleeding, we performed distal gastrectomy.The pathological diagnosis based on the resected speci- men was large-cell neuroendocrine carcinoma.After surgery, CPT-11/CDDP was continued but was switched to CPT-11 in June 2011 because of induced renal dysfunction.In November 2011, the regimen was switched to weekly paclitaxel because of a progressive increase in size of a solitary liver metastatic lesion located in S4-5.Two courses of this regimen were administered, but they were ineffective; therefore, we performed partial hepatectomy.No other recurrent lesions were observed during the surgery, and the patient was estimated to have achieved complete response(CR).After the surgery, no further adjuvant chemotherapy was administered.Four years after hepatectomy, the patient was diagnosed with esophageal cancer but exhibited no recurrence of the gastric cancer.We performed esophagectomy for the esophageal cancer in May 2016.T he patient is currently well without any relapse.

Phosphorylation of Thr(1495) of nestin in a mouse model of cerebral ischemia and reperfusion damage.

Nestin, a class VI intermediate filament protein, is expressed by neuronal progenitor cells in the subventricular zone (SVZ). In the present study, we analyzed the nestin expression and phosphorylation levels in nerve cells in a mouse model of cerebral ischemia and reperfusion. C57BL/6 mice were subjected to three-vessel occlusion for 14 min, and were killed either 1 or 4 days after the procedure. The percentages of cells in the SVZ that were positive for nestin, Thr(1495)-phosphorylated nestin or Ki67 did not significantly differ between the ischemic reperfusion and sham groups. Conversely, in the striatum and cornu ammonis 2 (CA2) regions, the mice at 4 days after ischemic reperfusion showed significantly higher numbers and percentages of nerve cells that were positive for nestin, Thr(1495)-phosphorylated nestin and Ki67 compared to results from the other groups. To our knowledge, this is the first description of phosphorylated nestin expression in neural progenitor cells in the SVZ of adult mice. In this cerebral ischemia and reperfusion mouse model, cells positive for Thr(1495)-phosphorylated nestin were increased in the striatum and CA2 field of the hippocampus; suggesting that nestin phosphorylation may play an important role in mitotically active neuronal progenitor cells.

New information technology tools for a medical command system for mass decontamination.

In a mass decontamination during a nuclear, biological, or chemical (NBC) response, the capability to command, control, and communicate is crucial for the proper flow of casualties at the scene and their subsequent evacuation to definitive medical facilities. Information Technology (IT) tools can be used to strengthen medical control, command, and communication during such a response. Novel IT tools comprise a vehicle-based, remote video camera and communication network systems. During an on-site verification event, an image from a remote video camera system attached to the personal protective garment of a medical responder working in the warm zone was transmitted to the on-site Medical Commander for aid in decision making. Similarly, a communication network system was used for personnel at the following points: (1) the on-site Medical Headquarters; (2) the decontamination hot zone; (3) an on-site coordination office; and (4) a remote medical headquarters of a local government office. A specially equipped, dedicated vehicle was used for the on-site medical headquarters, and facilitated the coordination with other agencies. The use of these IT tools proved effective in assisting with the medical command and control of medical resources and patient transport decisions during a mass-decontamination exercise, but improvements are required to overcome transmission delays and camera direction settings, as well as network limitations in certain areas.

Time course of recovery from cerebral vulnerability after severe traumatic brain injury: a microdialysis study.

BACKGROUND: The aim of this study was to evaluate the time course of recovery from cerebral vulnerability, using microdialysis (MD) technique and cerebral vascular autoregulation measurement, to clarify the appropriate timing of subsequent major surgical procedures, and to minimize the possibility of secondary brain injury in patients with severe traumatic brain injury (STBI). METHODS: In 3,470 MD samples of 25 patients with STBI, cerebral extracellular biomarkers (glucose, lactate, pyruvate, glycerol, and glutamate) were measured. In addition, to estimate cerebral vascular autoregulaton, the pressure reactivity index (PRx) was calculated with intracranial pressure (ICP) and mean arterial pressure. The data with ICP, cerebral perfusion pressure (CPP), and PRx were collected hourly for 7 days after injury and they were compared with MD biomarkers daily. RESULTS: During the study period, the average ICP and CPP remained stable and were within the threshold of STBI treatment guidelines. After injury, the extracellular glucose concentration decreased, and the levels of glycerol, glutamate, and lactate/pyruvate ratio (LPR), which indicate cerebral ischemia and neural cell damage, increased. On the fourth day after injury, the extracellular glucose concentration improved, and the value of LPR decreased. The average PRx decreased daily and became negative on the fifth day after injury. CONCLUSION: Our results indicated that cerebral vascular autoregulation would recover on the fourth day after STBI, and cerebral perfusion might be increased by recovery of autoregulation. Thus, subsequent nonemergent surgery should be performed at least 4 days after STBI to prevent secondary brain injury. In addition, we should keep in mind that the cerebral vulnerability might persist for 4 days after suffering STBI.

Treatment of Geriatric Traumatic Brain Injury: A Nationwide Cohort Study.

BACKGROUND: Because of the aging of the Japanese population, traumatic brain injuries (TBI) have increased in elderly adults. However, the effectiveness and prognosis of intensive treatment for geriatric TBI have not yet been determined. Thus, we used nationwide data from the Japan Neurotrauma Data Bank (JNTDB) projects to analyze prognostic factors for intensive and aggressive treatments. METHODS: We analyzed 1,879 geriatric TBI cases (age ≥65 years) registered in four JNTDB projects: Project 1998 (P1998) to Project 2015 (P2015). Clinical features, use of aggressive treatment, and 6-month outcomes on the Glasgow Outcome Scale (GOS) were compared among study projects. Logistic regression was used to identify prognostic factors in aggressively treated patients. RESULTS: The percentage of geriatric TBI cases significantly increased with time-P1998: 30.1%; Project 2004 (P2004): 34.6%; Project 2009 (P2009): 43.9%; P2015: 53.6%, p<0.0001). Use of aggressive treatment also significantly increased, from 67.0% in P1998 to 69.3% in P2015 (p<0.0001). Less invasive methods, such as trepanation and normothermic targeted temperature management, were more often chosen for geriatric patients. These efforts resulted in a significant decrease in the 6-month mortality rate, from 76.2% in P1998 to 63.1% in P2015 (p=0.0003), although the percentage of severely disabled patients increased, from 8.9% in P1998 to 11.1% in P2015 (p=0.0003). Intraventricular hemorrhage was the factor most strongly associated with unfavorable 6-month outcomes (OR 3.79, 95% CI 1.78-8.06, p<0.0001). CONCLUSIONS: Less invasive treatments reduced mortality in geriatric TBI but did not improve functional outcomes. Patient age was not the strongest prognostic factor; thus, physicians should consider characteristics other than age.

An analysis of Japan Disaster Medical Assistance Team (J-DMAT) deployments in comparison with those of J-DMAT's counterpart in the United States (US-DMAT).

Lessons learned from the Great Hanshin-Awaji earthquake of 1995 underscored the necessity of establishing Disaster Medical Assistance Teams (DMATs) in Japan, and in 2005, the Japanese government's Central Disaster Prevention Council revised its Basic Disaster Management Plan to include full deployment of DMATs in disaster areas. Defining a DMAT as a trained, mobile, self-contained medical team that can act in the acute phase of a disaster (48 to 72 hours after its occurrence) to provide medical treatment in the devastated area, the revised plan called for the training of DMAT personnel for rapid deployment to any area of the country hit by a disaster. This paper presents descriptive data on the number and types of missions carried out by Japan DMAT (J-DMAT) in its first 5 years, and clarifies how J-DMAT differs from its counterpart in the United States (US-DMAT). The DMAT that the present authors belong to has been deployed for 2 natural disasters and 1 man-made disaster, and the operations carried out during these deployments are analyzed. Reports on J-DMAT activities published from 2004 through 2009 by the Japanese Association for Disaster Medicine are also included in the analysis. After training courses for J-DMAT personnel started in fiscal 2004, J-DMATs were deployed for 8 disasters in a period of 4 years. Five of these were natural disasters, and 3 man-made. Of the 5 natural disasters, 3 were earthquakes, and of the 3 man-made disasters, 2 were derailment accidents. Unlike in the United States, where hurricanes and floods account for the greatest number of DMAT deployments, earthquakes cause the largest number of disasters in Japan. Because Japan is small in comparison with the US (Japan has about 1/25 the land area of the US), most J-DMATs head for devastated areas by car from their respective hospitals. This is one reason why J-DMATs are smaller and more agile than US-DMATs. Another difference is that J-DMATs' activities following earthquakes involve providing treatment in confined spaces, triage, and stabilization of injuries: these services are required in the acute phase of a disaster, but the critical period is over in a much shorter time than in the case of water-related disasters. In response the kind of man-made disasters that occur in Japan-mainly transportation accidents, and occasional cases of random street violence-J-DMATs need to be deployed as soon as possible to provide medical services at the scene at the critical stage of the disaster. This means that J-DMATs have to be compact. The fact that J-DMATs are smaller and more agile than US-DMATs is a result of the types of disaster that hit Japan and the relatively small size of the country.

PKC plays a crucial roles in c-mpl gene expression in megakaryoblastic cells.

Thrombopoietin is the cytokine involved in megakaryopoiesis and its receptor (c-Mpl) is considered to regulate development of megakaryocyte. In this research, to elucidate the underlying mechanisms of c-mpl gene expression in megakaryoblastic cells, we investigated the effect of a protein kinase C (PKC) on c-mpl promoter activity in a time-dependent manner. PKC is a member of a family of serine/threonine protein kinases in the cytosol involved in cell growth and differentiation. Phorbol 12-myristate 13-acetate (PMA) is known as PKC activator, significantly enhanced the c-mpl promoter activity and PKC inhibitor, 2-methylpiperazine dihydrochloride (H-7) suppressed the up-regulation of PMA-induced promoter activity and this effect decreased in a time-dependent manner. These results clearly suggest that in megakaryoblastic cells, PKC plays the crucial role in the initiation of up-regulation of PMA-induced c-mpl promoter activity.

Modulation mechanism of c-Mpl promoter activity in megakaryoblastic cells.

Thrombopoietin receptor (c-Mpl) is considered to regulate megakaryocytopoiesis. In this study, we investigated an effect of activation of a protein kinase C (PKC) on c-mpl promoter activity to elucidate the underlying mechanisms of c-mpl gene expression in megakaryoblastic cells. PKC is a member of a family of serine/threonine protein kinases in the cytosol involved in cell growth and differentiation. Phorbol 12-myristate 13-acetate (PMA) is known as PKC activator, significantly enhanced the c-mpl promoter activity and PKC inhibitors (H7, GF109203) suppressed the up-regulation of PMA-induced promoter activity and reduced the steady level of its activity. These results strongly suggest that PKC plays the essential role in the modulation of c-mpl promoter activity of megakaryoblastic cells.

Feasibility of Human Neural Stem Cell Transplantation for the Treatment of Acute Subdural Hematoma in a Rat Model: A Pilot Study.

Human neural stem cells (hNSCs) transplantation in several brain injury models has established their therapeutic potential. However, the feasibility of hNSCs transplantation is still not clear for acute subdural hematoma (ASDH) brain injury that needs external decompression. Thus, the aim of this pilot study was to test feasibility using a rat ASDH decompression model with two clinically relevant transplantation methods. Two different methods, in situ stereotactic injection and hNSC-embedded matrix seating on the brain surface, were attempted. Athymic rats were randomized to uninjured or ASDH groups (F344/NJcl-rnu/rnu, n = 7-10/group). Animals in injury group were subjected to ASDH, and received decompressive craniectomy and 1-week after decompression surgery were transplanted with green fluorescent protein (GFP)-transduced hNSCs using one of two approaches. Histopathological examinations at 4 and 8 weeks showed that the GFP-positive hNSCs survived in injured brain tissue, extended neurite-like projections resembling neural dendrites. The in situ transplantation group had greater engraftment of hNSCs than matrix embedding approach. Immunohistochemistry with doublecortin, NeuN, and GFAP at 8 weeks after transplantation showed that transplanted hNSCs remained as immature neurons and did not differentiate toward to glial cell lines. Motor function was assessed with rotarod, compared to control group (n = 10). The latency to fall from the rotarod in hNSC in situ transplanted rats was significantly higher than in control rats (median, 113 s in hNSC vs. 69 s in control, P = 0.02). This study first demonstrates the robust engraftment of in situ transplanted hNSCs in a clinically-relevant ASDH decompression rat model. Further preclinical studies with longer study duration are warranted to verify the effectiveness of hNSC transplantation in amelioration of TBI induced deficits.

Cervical spinal cord injury without bony injury: a multicenter retrospective study of emergency and critical care centers in Japan.

BACKGROUND: To demonstrate the clinical characteristics of patients with cervical cord injury (CCI) without bony injury in Japan. METHODS: Retrospective review of 127 patients with CCI without bony injury treated between January 2003 and October 2005 at 11 institutions. RESULTS: Prevalence of CCI without bony injury was 32.2% among all CCIs and 0.81% among all blunt traumas. Mean age was 60.4 years (range, 19-90 years), with 104 patients (82%) > or = 46 years old (older group). The major mechanism of injury among younger patients (< 46 years) was traffic injuries (39%), whereas minor falls (44%) predominated in older patients. High-energy mechanisms of injury were significantly more common for younger patients (35% versus 15%, p = 0.041). Mean injury severity score, abbreviated injury score for the head and Glasgow coma scale on admission were 17.2 +/- 4.7, 0.6 +/- 0.9, and 14.2 +/- 2.1, respectively. Incomplete CCI occurred in 88.7%. On plain cervical spine radiography, spinal canal stenosis and spondylosis or ossification of the posterior longitudinal ligament were more frequent in older patients than in younger patients (43% vs. 13%, p = 0.008; 54% vs. 17%, p = 0.002, respectively). No abnormal findings were seen in 52% of younger patients. CONCLUSION: CCI without bony injury occurred more frequently in this study population than previously reported. Degenerative changes and spinal canal stenosis represent important risk factors for developing CCI without bony injury and the present results suggest that this injury may occur in younger adults during high-energy injuries in the absence of pre-existing cervical spine disease.

Reconstruction methods after total pharyngolaryngoesophagectomy: free jejunal graft and venous-reconstructed gastric tube or gastric tube alone.

BACKGROUND/AIMS: The aim of this study is to assess the postoperative outcome of the two reconstruction methods using both a free jejunal graft and a venous-reconstructed gastric tube or a gastric tube alone after total pharyngolaryngoesophagectomy. METHODOLOGY: We reconstructed the pharyngoesophagus using both a free jejunal graft and a gastric tube in 5 cases (JG group), including 4 in whom the gastric vein was reconstructed, and using a gastric tube alone in 8 cases (G group). We compared the two groups in terms of postoperative complications, operation time, blood loss and length of postoperative hospital stay. RESULTS: In the JG group, jejunal graft necrosis occurred in a case, although 4 cases with gastric venous reconstruction had no postoperative problems. In the G group, although anastomotic trouble occurred in 3 cases, 7 patients were discharged from hospital with oral feeding. In the JG group, postoperative stay was shorter, but the operation time was longer, than those in the G group. CONCLUSIONS: Reconstruction using a free jejunal graft and a venous-reconstructed gastric tube is useful especially for patients with a long defect in the pharyngoesophagus. These 2 methods may be used according to the length of the pharyngoesophageal defect.

Living donor liver transplantation for type II citrullinemia from a heterozygous donor.

Adult-onset type II citrullinemia (CTLN2) is a rare disorder of the urea cycle resulting in hyperammonemia, with a poor prognosis. Here we report a 48-year-old Japanese man who showed abnormal nocturnal behavior. Laboratory data indicated raised plasma concentrations of ammonia and citrulline, and a definitive diagnosis of CTLN2 was made by DNA analysis. Hyperammonemia was not improved by oral intake of branched-chain amino acids (BCAA), whereas venous infusion of BCAA was effective. Western blotting revealed heterozygotic expression of citrin protein in a liver biopsy specimen from the patient's brother. However, as symptomatic CTLN2 is very unusual in a heterozygotic carrier, we considered the brother suitable as a living-donor liver transplantation (LDLT) donor. The recipient's entire liver was removed, and replaced with the left liver graft. The plasma ammonia level remained low without infusion of BCAA after liver transplantation. From this case we conclude that venous infusion, rather than oral administration, of BCAA is useful for conservative treatment of CTLN2. However, liver transplantation is the only effective therapeutic option for CTLN2, and should be performed before irreversible encephalopathy occurs. Use of a graft from heterozygotic donors is permissible treatment for CTLN2.

Quantitative pupillometry and neuron-specific enolase independently predict return of spontaneous circulation following cardiogenic out-of-hospital cardiac arrest: a prospective pilot study.

This study aimed to identify neurological and pathophysiological factors that predicted return of spontaneous circulation (ROSC) among patients with out-of-hospital cardiac arrest (OHCA). This prospective 1-year observational study evaluated patients with cardiogenic OHCA who were admitted to a tertiary medical center, Nippon Medical School Hospital. Physiological and neurological examinations were performed at admission for quantitative infrared pupillometry (measured with NPi-200, NeurOptics, CA, USA), arterial blood gas, and blood chemistry. Simultaneous blood samples were also collected to determine levels of neuron-specific enolase (NSE), S-100b, phosphorylated neurofilament heavy subunit, and interleukin-6. In-hospital standard advanced cardiac life support was performed for 30 minutes.The ROSC (n = 26) and non-ROSC (n = 26) groups were compared, which a revealed significantly higher pupillary light reflex ratio, which was defined as the percent change between maximum pupil diameter before light stimuli and minimum pupil diameter after light stimuli, in the ROSC group (median: 1.3% [interquartile range (IQR): 0.0-2.0%] vs. non-ROSC: (median: 0%), (Cut-off: 0.63%). Furthermore, NSE provided the great sensitivity and specificity for predicting ROSC, with an area under the receiver operating characteristic curve of 0.86, which was created by plotting sensitivity and 1-specificity. Multivariable logistic regression analyses revealed that the independent predictors of ROSC were maximum pupillary diameter (odds ratio: 0.25, 95% confidence interval: 0.07-0.94, P = 0.04) and NSE at admission (odds ratio: 0.96, 95% confidence interval: 0.93-0.99, P = 0.04). Pupillary diameter was also significantly correlated with NSE concentrations (r = 0.31, P = 0.027). Conclusively, the strongest predictors of ROSC among patients with OHCA were accurate pupillary diameter and a neuronal biomarker, NSE. Quantitative pupillometry may help guide the decision to terminate resuscitation in emergency departments using a neuropathological rationale. Further large-scale studies are needed.

Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein.

Preservation of the spleen at distal pancreatectomy has recently attracted considerable attention. Since our first successful trial, spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for tumors of the pancreas and chronic pancreatitis has been performed more frequently. The technique for spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein are outlined. The splenic vein is identified behind the pancreas and within the thin connective tissue membrane. The connective tissue membrane is cut longitudinally above the splenic vein. An important issue is to remove the splenic vein from the body of the pancreas toward the spleen, since a different approach may be very difficult. The pancreas is preferably removed from the splenic artery toward the head of the pancreas itself. This procedure is much easier than removing the pancreas from the vein side. One patient had undergone distal gastrectomy for duodenal ulcer, with reconstruction by Billroth II technique. If distal pancreatectomy with splenectomy had been performed for the lesion of the distal pancreas at the time, the residual stomach would also have to be resected. The potential damage done to the patient by reconstruction of the gastrointestinal tract in combination with distal pancreatectomy and splenectomy would have been much greater than with distal pancreatectomy only with preservation of the spleen and residual stomach. Benign lesions as well as low-grade malignancy of the body and tail of the pancreas may be a possible indication for this procedure.

Definition of MCN (mucinous cystic neoplasm of the pancreas) and a proposal for a new concept of MRN or MSN (mucinous round or spherical neoplasm).

The differential diagnosis of IPMN and MCN is very important for clinicians. MCN is reported to develop in middle-aged females (mean age 48 years) and in the body and tail of the pancreas. Some doctors insist that ovarian-like stroma is absolutely necessary for the definition of MCN. Prompt resection of MCN after diagnosis is desirable. In contrast, about 60% of cases with branch-type IPMN do not require an operation. Therefore, one of the important goals in the differential diagnosis of MCN and branch-type IPMN is to determine the surgical indications before the operation. We believe that MCN and IPMN should be defined by imaging procedures before the operation. We suggest that a neoplasm with an appearance similar to an orange should be diagnosed as MCN, while that with an appearance similar to a bunch of grapes in MRCP should be diagnosed as branch-type IPMN. Proposal of a new concept: If the term MCN is restricted to neoplasms that exhibit ovarian-like stroma, we propose that lesions which are surrounded by a very thick capsule, and which show an orange-like appearance by imaging procedures without histological ovarian-like stroma should be called MRN (mucinous round neoplasm) or MSN (mucinous spherical neoplasm).

A drainage operation for injury to the pancreas preserved the distal pancreas, spleen and the residual stomach after distal gastrectomy: a case report.

We experienced a case in which a drainage operation for injury of the pancreas preserved the distal pancreas, spleen and the residual stomach after distal gastrectomy for complete laceration of the stomach. A 23-year-old male was crushed by a large truck while driving a car without a seat belt. Abdominal computed tomography (CT) scan showed a low-density area in and around the body of the pancreas, which suggested contusion of the pancreatic parenchyma. An emergent operation was indicated due to free air and massive bleeding in the abdominal cavity and liver damage. At the operation, the antrum of the stomach was completely lacerated and distal gastrectomy was performed. Drains were set around the body of the pancreas. Distal pancreatectomy with splenectomy would have led to total gastrectomy because of lack of blood supply to the residual stomach after distal gastrectomy. We limited the drainage operation for pancreatic trauma. As a result, the pancreatic body and tail were preserved, which is thought to be a much better long-term result for this patient.

Twelve years survival with repeated hepatectomy and lung resection for metastasis from carcinoma of the papilla of Vater after pancreaticoduodenectomy.

We present a 60-year-old woman who underwent three times hepatectomy and lung resection for metastasis originating from a carcinoma of the papilla of Vater after pancreaticoduodenectomy with lymphadenectomy during 12 years. Pancreaticoduodenectomy was performed in 1980 and histological examination of original tumor revealed a stage IIA papillary adenocarcinoma (pT3, pN0, pM0). Repetitive hepatectomy underwent in 1986 (S7,8), 1988 (S2), 1991 (S4) and bilateral partial resection of lung (right S1, left S2.3) in 1990. She died from multiple skin, bone and lung metastases 12 years after pancreaticoduodenectomy. The current case is very rare, however, if patients with carcinoma of the papilla of Vater have localized liver metastases and no local recurrence, liver metastases should be resected to improve the chances for long-term survival.