Serum total bilirubin elevation is a predictor of the clinicopathological severity of acute appendicitis.

PURPOSE: Elevation of the serum total bilirubin (STB) level not stemming from hepatic dysfunction or biliary obstruction may be seen in cases of acute appendicitis. This paper deals with the clinical significance of such elevations. METHODS: Data from 410 appendectomized patients classified into two groups (a high preoperative STB group and a normal preoperative STB group) were analyzed to reveal the significance of preoperative hyperbilirubinemia. We also examined whether the preoperative STB level might serve as a risk factor for gangrenous appendicitis by a multivariate analysis. RESULTS: Gangrenous appendicitis was more common in the high preoperative STB group (p < 0.001). The multivariate analysis revealed that an elevated preoperative STB level (odds ratio 1.7919) was a risk factor for gangrenous appendicitis. CONCLUSION: In patients with an elevated preoperative STB level, it is very likely that the inflammation is severe and that the disease has progressed to a severe condition histopathologically; therefore, meticulous attention should be paid to the selection of the surgical procedure, as well as to the postoperative clinical course.

Two successful curative operations using stomach-preserving distal pancreatectomy with celiac axis resection for the treatment of locally advanced pancreatic body cancer.

Large vessel invasion is a serious factor determining whether an operation for pancreatic body cancer is feasible. The Appleby operation is a radical operation for the treatment of pancreatic body cancer that has infiltrated the celiac axis. Since this procedure includes a total gastrectomy, the operation is associated with a high morbidity, mortality, and deteriorating postoperative quality of life (QOL). We experienced two cases in which radical operations consisting of a stomach-preserving distal pancreatectomy with en bloc resection of the celiac, common hepatic, and left gastric artery were performed. The use of adjuvant chemotherapy in these cases led to a good postoperative QOL.

Successful treatment of a colonic ulcer penetrating the urinary bladder caused by the administration of calcium polystyrene sulfonate and sorbitol.

A 77-year-old woman was urgently admitted for the treatment of diabetic ketoacidosis and a duodenal ulcer hemorrhage in March 1999. She had a history of diabetes and angina pectoris. After admission, she received oral calcium polystyrene sulfonate and sorbitol to treat hyperkalemia. Nine days later, severe abdominal pain developed. A colonoscopic examination revealed a sigmoid colonic ulcer and stenosis; the patient was treated conservatively. At a 1-year follow-up examination, the colonic stenosis was found have worsened; pneumaturia developed in January 2001. The patient was found to have a sigmoidovesical fistula and underwent sigmoidectomy and partial resection of the ileum and urinary bladder. The histological findings were a benign colonic ulcer with the infiltration of inflammatory cells, mainly lymphocytes. Rhomboidal, dark violet Kayexalate crystals were observed on microscope examination in the submucosa in both the first and second colonic biopsy specimens. We concluded that the colonic ulcer and the sigmoidovesical fistula had been caused by the administration of calcium polystyrene sulfonate and sorbitol. Reports of colonic perforation as a result of the administration of calcium polystyrene sulfonate and sorbitol are rare. Here, we report the successful treatment of a colonic ulcer that had penetrated the urinary bladder.

Significance of gastrectomy as palliative surgery for gastric carcinoma with pyloric stenosis.

We conducted a clinicopathological study of cases of gastric carcinoma with pyloric stenosis and examined treatment outcomes and the prognosis of cases of stage IV gastric carcinoma with pyloric stenosis and the validity of gastrectomy as palliative surgery in these cases. The outcomes of 49 surgeries for gastric carcinoma with pyloric stenosis were compared with those of 671 surgeries for gastric carcinoma without pyloric stenosis. The diagnosis of pyloric stenosis was confirmed with both upper gastrointestinal endoscopy and an upper gastrointestinal barium series. The frequency of pyloric stenosis in patients with gastric carcinoma was 7.3%. Serosal invasion was observed in about 70% of all cases. Of these cases, 53.1% were classified as stage IV. The resection rate was 73.5%, and the resection was classified as curative in 44.9% of cases. The incidence of complications after surgery in cases of stage IV gastric carcinoma was 47.1%. The median survival time was significantly greater in patients undergoing resection group than in those not undergoing resection (p=0.025). Most patients with gastric cancer and pyloric stenosis can be considered to have stage IV disease, which is associated with high rates of morbidity and mortality; thus, prevention of complications, and therefore, avoidance of gastrectomy is recommended in such patients. Nonetheless, in this study, gastrectomy was shown to improve prognoses in these patients.

Successful use of endoscopic argon plasma coagulation for patients with early gastric cancer and diabetes mellitus.

We report on two patients with gastric tumors (early cancer and adema) and diabetes mellitus who were treated with argon plasma coagulation (APC) therapy. Case 1. A 78-year-old woman visited the Nippon Medical School Musashi Kosugi Hospital because of epigastric pain. An early gastric cancer (IIc) in the anterior wall of the gastric antrum was diagnosed on the basis of the results of a gastric endoscopy examination. The patient had had diabetes mellitus for 18 years and had injected insulin (NovoRapid 30 Mix, 72 units/day) by herself everyday for 10 years. Case 2. A 61-year-old man was referred to our hospital because of a gastric tumor. A gastric adenoma in the anterior of the gastric antrum was diagnosed on the basis of the results of a gastric endoscopy examination. The patient had had diabetes mellitus for 12 years and had been taking oral medication for 2 years. Endoscopic APC was performed in both patients to remove the gastric tumors. These patients have been well for 28 months and 30 months, respectively, after undergoing APC treatment. APC therapy appears to be a safe and useful treatment for patients with diabetes and gastric mucosal lesions.

Case of intra-abdominal endocrine tumor possibly arising from an ectopic pancreas.

We report an intra-abdominal endocrine tumor possibly arising from an ectopic pancreas. A 45-year-old woman visited the Nippon Medical School Musashi-Kosugi Hospital because of right-sided hypochondralgia and upper abdominal discomfort of 1 years duration. An intra-abdominal tumor was diagnosed on the basis of the results of an ultrasound examination, computed tomography and magnetic resonance. Surgery was subsequently performed using laparoscopic techniques, and a tumor without firm adhesions was found near the wall of the duodenal bulbus. The tumor was easily removed; the resected specimen (55 x 45 x 25 mm, 50 g) was composed of bloody fluid within a cystic tumor. Histological and immunohistochemical examinations of the tumor showed a type 3 ectopic pancreas, according to the classification proposed by Heinrich. The patients recovery was uneventful.

Primary Volvulus of the Small Intestine Exhibiting Chylous Ascites: A Case Report.

BACKGROUND: Primary volvulus of the small intestine associated with chylous ascites is very rare, with only four reported cases. In this paper, we report a new case of primary volvulus associated with chylous ascites. CASE PRESENTATION: The patient was a 70-year-old man. After experiencing bloating and abdominal pain for several hours, he called an ambulance and underwent an emergency examination at our hospital. Abdominal distension, pressure pain, and rebound tenderness were observed throughout his entire abdomen. The patient had a history of hypertension for which he was receiving oral treatment. Abdominal contrast-enhanced computed tomography (CT) revealed an edematous change in the intestinal membrane and volvulus of the small intestine. As findings suggestive of ischemia were observed in part of the intestines, emergency surgery was performed on the day of admission. Open surgery revealed approximately 500 mL of chylous ascites in the abdominal cavity. The small intestine had twisted 180° in a counter-clockwise direction at the root of the superior mesenteric artery, and the mesentery appeared milky white with edematous changes extending 75 to 240 cm from the ligament of Treitz. There was no evidence of intestinal necrosis; therefore intestinal resection was not performed. The volvulus of the small intestine was corrected. Moreover, because there was no other underlying disease observed, surgery was completed. The ascites collected during surgery revealed high levels of triglycerides at 332 mg/dL, and chylous ascites was diagnosed. An abdominal CT performed on the third day after surgery showed an improvement in intestinal edema, and primary volvulus of the small intestine associated with chylous ascites was diagnosed. Postoperative progress was good, and the patient was discharged on hospital day 10.

Helicobacter pylori infection with a duodenal ulcer in a 6-year-old boy.

A 6-year-old boy was hospitalized because of dark feces and facial pallor of 1 weeks duration. Other gastrointestinal symptoms, including vomiting and abdominal pain, were absent, but he felt dizziness when standing and fatigue on effort. Hematologic studies revealed iron-deficiency anemia, and endoscopy showed gastric erosions and a duodenal ulcer. All test results for Helicobacter pylori infection, including H. pylori antigen in stool, anti-H. pylori IgG immunoassay in serum, and the (13)C-urea breath test, were positive. Because an H. pylori-associated gastric ulcer had been diagnosed with endoscopy in the patients father 3 years earlier, father-son transmission was suspected. The patient was treated with triple-agent eradication therapy (proton pump inhibitor [lansoprazol], amoxicillin, and clarithromycin) for 2 weeks. One month after therapy was completed, eradication of H. pylori was confirmed by negative results on the stool antigen test. Peptic ulcer disease can occur in young children, as in this case. The stool antigen test kit is a useful and reliable method that can be used even in preschool children to diagnose H. pylori infection.

A reversible resistivity-based nitric oxide sensor.

A sensor for nitric oxide is reported that uses a novel redox matching mechanism to induce a resistance change upon binding this important ligand to cobalt.

Metachronous adenocarcinoma occurring at a colostomy site after abdominoperineal resection for rectal carcinoma.

Carcinomas rarely occur at the site of a colostomy. A 73-year-old man underwent abdominoperineal resection (Miles' surgical procedure) for rectal carcinoma in September 1988. He did not return to the hospital until September 1995, when he was admitted with stricture of the stoma. Neither tumor nor ulcer was detected at the stoma. The tip of the doctor's little finger was able to pass through the stoma, and manual expanding alleviated the stricture. The patient did not return to the hospital again until August 1996, at age 81 years, when he visited the hospital because of complete stricture of the stoma. A biopsy revealed an adenomatous carcinoma, but the results of various examinations suggested no metastasis. A portion of the intestine, including the stoma and surrounding skin, was resected, and a new stoma was created in the descending colon. We report this rare carcinoma occurring at the site of a colostomy, and we review the literature.

Cure of intractable pancreatic fistula by subcutaneous fistulojejunostomy.

Fistulojejunostomy was performed at the subcutaneous level in two patients with intractable pancreatic fistula that occurred after surgery for cancer of the ampulla of Vater and carcinoma of the lower bile duct. The treatment yielded mostly satisfactory results, though one patient incurred postoperative wound dehiscence, which was healed with conservative measures. Compared with conventional procedures, this method is technically easy to perform, as it does not involve surgical separation of the fistula up to a site deep within the abdominal cavity, rarely results in side injury, and poses few potential risks of cicatricial stenosis of the fistular lumen, because blood supply to the fistula is preserved. Subcutaneous fistulojejunostomy is considered to be recommendable for pancreatic fistulas that occur long after surgery and which are stenosed at the site of the pancreatojejunal stenosis and thus require surgical treatment.

Facilitated sulfate transfer across the nitrobenzene-water interface as mediated by hydrogen-bonding ionophores.

Facilitated SO4(2-) transfers by hydrogen bond-forming ionophores are investigated across the nitrobenzene (NB)-water interface by using polarography with a dropping electrolyte electrode. Bis-thiourea 1, alpha,alpha'-bis(N'-p-nitrophenylthioureylene)-m-xylene, is found to significantly facilitate the transfer of the highly hydrophilic SO4(2-) whereas its counterpart, N-(p-nitrophenyl)-N'-propylthiourea (ionophore 2), cannot. In contrast to the predominant formation of a 1:1 complex with SO4(2-) in the bulk NB phase, the SO4(2-) transfer assisted by 1 is indeed based on the formation of a 1:2 complex between SO4(2-) and ionophore, even under the condition of [SO4(2-)]aq >> [1]org. Such an exclusive formation of the 1:2 (SO4(2-) to ionophore) complex at the NB-water interface is not observed with structurally similar bis-thiourea 3, alpha,alpha'-bis(N'-phenylthioureylene)-m-xylene, where p-nitrophenyl moietes of bis-thiourea 1 are simply replaced by phenyl groups. The facilitated transfer of SO4(2-) with bis-thiourea 1 is further compared to that of HPO4(2-) and H2PO4- across the NB-water interface, which was previously shown to be assisted by 1 through the formation of the 1:1 and 2:1 (anion to ionophore) complexes, respectively. On the basis of these examinations, unique binding behaviors of hydrogen bond-forming ionophores at the NB-water interface are discussed, with a view towards development of ionophore-based anion-selective chemical sensors.

Four-year survival of a patient with malignant fibrous histiocytoma of the liver treated with surgery and chemotherapy.

Malignant fibrous histiocytoma of the liver is an extremely rare tumor. A 43-year-old woman was admitted with an enlargement of the abdomen and a feeling of general fatigue. A clinical examination revealed a right liver giant cystic tumor (18.5 × 22 cm). The cystic tumor, which contained a solid component, occupied almost the entire right lobe of the liver, and a solid S4 tumor was also observed. A blood examination revealed severe anemia and mild liver dysfunction. During hospitalization intratumor bleeding occurred. A right lobectomy of the liver and lymph node dissection was performed after transcatheter arterial embolization. Histopathologically, the tumor was diagnosed as a primary storiform-pleomorphic-type malignant fibrous histiocytoma of the liver. One year after the radical operation, the patient developed recurrences in other organs. She received 17 cycles of chemotherapy with etoposide, ifosfamide, and cisplatin. The recurrent tumors decreased in size, but new recurrences in other organs occurred. The patient died of respiratory failure 4 years and 2 months after the initial operation.

Low-pressure continuous suction of bile and pancreatic juice from the hepatic duct and jejunal limb after major hepatectomy with pancreatoduodenectomy.

We describe an effective technique for the low-pressure continuous suction of bile and pancreatic juice from the hepatic duct and jejunal limb after major hepatectomy with pancreatoduodenectomy (PD). After hepatectomy and PD, reconstruction is performed by a modification of Child's method. A pancreaticojejunostomy is completed with interrupted sutures between the pancreatic duct and mucosa, without inserting a stent. During hepaticojejunostomy, a 10-F silicone drain with side channels (Blake Silicone Drain; Ethicon, Somerville, NJ, USA) is placed within the hepatic duct via the stump of the jejunal limb to drain bile and pancreatic juice. The drain is connected to a continuous suction device and low suction pressure is started. We found that the low-pressure continuous suction of bile and pancreatic juice from the hepatic duct and jejunal limb was very effective after major hepatectomy with PD.

Synthesis and properties of highly fluorescent indolizino[3,4,5-ab]isoindoles.

We report here the synthesis, X-ray structures, optical and electrochemical properties, fabrication of light-emitting devices, and density functional calculations for indolizino[3,4,5-ab]isoindole (INI) derivatives. Strongly luminescent heterocycles based on the INI unit were synthesized by 1,3-dipolar cycloaddition reactions between pyrido[2,1-a]isoindole (PIS) and acetylene or ethylene derivatives. They are indolizino[3,4,5-ab]isoindoles 2-9 and 14-15, benzo[1',2'-1,2]indolizino[3,4,5-ab]isoindoles 10, pyridazino[4',5':1,2]indolizino[3,4,5-ab]isoindoles 12-13, and 2,3-hydropyridazino[4',5':1,2]indolizino[3,4,5-ab]isoindole-1,4-dione 11. The relative luminescence quantum yield can be as high as 90%. Their reduction and oxidation potentials and high luminescence can make these heterocycles possible alternatives to tris(8-hydroxyquinolinato)aluminum (Alq(3)). The brightness of the light-emitting device reached as high as 10(4) cd/m(2) and indolizino[3,4,5-ab]isoindole 3 emits beautifully blue light. The X-ray crystal structures of INI derivatives were obtained for the first time. The geometries obtained from X-ray data and density functional theory calculations shed more light on an interesting formally antiaromatic 16pi system, which is divided into 10pi and 6pi aromatic systems. We also report a relatively easy protonation of INI, which occurs at a carbon, rather than nitrogen atom.