[Pancreatic cancer in a patient with congenital agenesis of the dorsal pancreas].

A 65-year-old man with back pain showed a hypovascular lesion of the head of the pancreas on dynamic computed tomography and abdominal ultrasonography. The distal portion of the pancreas was not visible. Endoscopic retrograde cholangiopancreatography revealed pancreatic duct obstruction, and the duodenal minor papilla was not visible. Therefore, we diagnosed the patient's condition as stage IVa pancreatic cancer with congenital agenesis of the dorsal pancreas. The patient underwent successful chemotherapy with 3 courses of gemcitabine and S-1, which was followed by pancreaticoduodenectomy. Pathological staging revealed invasive ductal carcinoma, pT3, pN0, pM0, stage III. We report a rare case of pancreatic cancer with congenital agenesis of the dorsal pancreas.

Laparoscopic surgery in a patient with foramen of Winslow hernia due to large uterine fibroids: a case report and literature review.

BACKGROUND: Foramen of Winslow hernia (FWH) is a rare but emergent condition caused by an increase in the foramen diameter, visceral mobility, and intra-abdominal pressure. To the best of our knowledge, this is the first study to report a case of FWH secondary to large uterine fibroids that was successfully treated with laparoscopic surgery. CASE PRESENTATION: A 52-year-old woman with large uterine fibroids was diagnosed with FWH. Because of the absence of signs of bowel ischemia and peritonitis, we performed an elective laparoscopic surgery through a 5-port system after bowel decompression using a long intestinal tube. Although foramen of Winslow closure was not performed, her postoperative course was uneventful. CONCLUSIONS: Laparoscopic surgery for FWH is considered an extremely effective surgical treatment option because of its safety and efficacy in performing delicate procedures (such as adhesiolysis) with a good magnified field of view.

A recurrent case of an early gallbladder carcinoma after laparoscopic cholecystectomy.

A 71-year-old woman diagnosed with gallstones and chronic cholecystitis was admitted to our hospital in October 1997, and laparoscopic cholecystectomy was performed. After the operation, early gallbladder carcinoma, which had superficially spread to the whole gallbladder restricted to mucosa (pT1a) by histology, was identified. Six weeks later, liver bed resection, bile duct dissection and regional lymph node dissection were performed. Histological examination revealed that cancer cells had been microscopically disseminated to the hepatoduodenal ligament and invaded into the lymphatic vessels. The postoperative course was uneventful. She died of peritoneal recurrence of her gallbladder cancer 14 months after the second operation.

[A patient with peritoneal metastasis from gastric cancer who responded to weekly chemotherapy with paclitaxel on the third line and could take meal].

We report a patient with peritoneal metastasis from gastric cancer who responded to weekly chemotherapy with paclitaxel (TXL) as the third line treatment and could take meals for half a year. The patient was a 64-year-old man who underwent total gastrectomy for advanced gastric cancer with peritoneal metastasis. He was first treated with TS-1 as an outpatient treatment; however, tumor markers rose. He could not take meals and had to be hospitalized. CPT-11 was infused on the second line, but due to disease progress, the patient was administered weekly TXL. TXL (70 mg/m2) was infused over 1 hour after short premedication. Administration was continued for 3 weeks followed by 1 week rest. The tumor markers decreased, and he could take meals and was discharged from hospital. The toxic events were leukopenia (grade 2), alopecia (grade 2) and pneumonia (grade 3).

Changes in extrathymic T cells in the liver and intestinal intraepithelium in mice with obstructive jaundice.

Recently, T cells were classified into two categories: intrathymic T cells (ITCs; thymus-derived T cells) and extrathymic T cells (ETCs). ETC, localized in the liver and intestinal intraepithelium (IE), play an important immunologic role in the suppressed condition of T-cell development in the thymus. Given the fact that complications of surgery in patients with obstructive jaundice are often related to immunosuppression in the gut-liver circulation, we attempted to investigate the changes in the proportion of ETCs in mice with obstructive jaundice. Three mice models were prepared ( n = 10 per group): sham group with simple laparotomy; ligation group with common bile duct ligation; deoxycholic acid (DCA) group with an oral intake of DCA as a model of the presence of bile salts in the gut lumen. In each model, total mononuclear cells (MNCs), ITCs in the thymus, and ETCs in the liver and IE were counted using monoclonal antibodies in conjunction with a two-color immunofluorescence test by flow cytometry. In the ligation group the number of MNCs was reduced in the thymus and IE, and only those in the IE recovered after oral intake of DCA. A decrease of ITCs in the thymus and the increase in ETCs in the liver and IE occurred simultaneously during the early phase of biliary obstruction. At day 7 after biliary obstruction, ETCs in the livers of the DCA and ligation groups decreased to nearly the level in the sham group. However, on day 7 the ETCs in the IE remained significantly higher in the DCA group than in the ligation group. These results suggested that ETCs can act in place of ITCs at an early phase of obstructive jaundice, and the presence of bile in the gut lumen may be associated with the consumption of ETCs in the IE, a reaction that may bring about improved immunoreactivity.

Does radical resection improve the survival in patients with carcinoma of the gallbladder who are 75 years old and older?

Radical resections have been reported to improve the surgical outcome for patients with carcinoma of the gallbladder. In recent years surgeons have had more opportunities to operate on elderly patients. We investigated whether the survival rate of aged patients who had radical resections were better than rates for those who had simple cholecystectomy. Of the 300 patients treated for carcinoma of the gallbladder between 1971 and 1999, 206 resected cases (except pancreaticoduodenectomy and hepatectomy) were divided into two groups: age 75 years or older, 54 patients (the older group), and age less than 75 years, 152 patients (the younger group). Clinical features and progression of the carcinomas did not differ between the two groups. In the older group, 22 patients (40.7%) had simple cholecystectomy, 32 (59.3%) had radical resections; in the younger group, 65 patients (42.8%) had simple cholecystectomy, and 87 (57.3%) had radical resection. None of the older patients who had radical resection died postoperatively. Postoperative survival was not different between the two groups. In the older group the 5-year survival rate for patients who had radical resections was better (60.9%) than the rate for those who had simple cholecystectomy (14.1%) (p = 0.0098). Radical resection is effective for the aged patients with the carcinoma of gallbladder.

Short-term effects of external and internal biliary drainage on liver and cellular immunity in experimental obstructive jaundice.

BACKGROUND/PURPOSE: The effects of preoperative biliary drainage for obstructive jaundiced patients are controversial. Although experimental studies have proven the benefit of internal biliary drainage (ID) over external biliary drainage (ED), ID has several clinical problems, such as clogging or tube replacement. The aim of this study was to determine whether there were any differences in T-cell function, liver function, and histology, between rats in ID and ED groups in short-term experiments. METHODS: Following bile duct ligation (BDL) for 14 days, rats in the ED and ID groups had 7 days of ED and 7 days of ID, respectively. Normal rats were used as negative controls (control group). For positive controls, we used a group with BDL and no drainage (BDL group). Serum bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) were measured, splenic T-cell proliferation was assayed to check cellular immunity, and liver histology was examined. RESULTS: Recovery of bilirubin and ALT was similar in the ED and ID groups. Recovery of AST was worse in the ID group than in the ED group, but the difference was not statistically significant. Levels of ALP in the BDL and ID groups were significantly higher than those in the control and ED groups. Rats in the BDL group showed a significant decrease in T-cell function compared to the control group. The ED group showed better recovery of T-cell function than the ID group in the 7 days after relief of obstructive jaundice. The livers in the ID group demonstrated histologically moderate interface hepatitis with periportal inflammation and lymphocyte infiltration, which strongly suggested incomplete tube obstruction, but those in the ED group showed minimal change. CONCLUSIONS: ED is superior to ID concerning the recovery of cellular immunity and liver inflammation in the short-term after relief from biliary obstruction in this model. As the patency of the tube is well maintained in ED compared to ID, patency of the tube is essential to obtain good recovery of cellular immunity, irrespective of the drainage method.

Effect of a selective inhibitor of secretory phospholipase A2, S-5920/LY315920Na, on experimental acute pancreatitis in rats.

We investigated the efficacy of a potent inhibitor of secretory phospholipase A2 (sPLA2), S-5920/LY315920Na, in an experimental model of acute pancreatitis in rats. Combined intraductal injection of sodium taurocholate (5 mg/rat) and porcine pancreatic sPLA2-IB (300 microg/rat) caused severe hemorrhagic necrotizing pancreatitis resulting in high mortality, along with rapid increases of catalytic PLA2 and lipase activities in plasma and ascites and with gradual increases of plasma amylase and aspartate aminotransferase levels over 9 h after the pancreatitis. Prophylactic intravenous treatment with S-5920/LY315920Na significantly reduced mortality at 7 days, and strongly abrogated PLA2 activities in both plasma and ascites along with significant reduction of lipase activity, amylase, aspartate aminotransferase, and hemorrhage at 6 h. It also significantly reduced histological damage such as edema and parenchymal and fat necroses of the pancreatic tissue. This sPLA2 inhibitor could become an effective agent for the treatment of severe acute pancreatitis.