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Purpose: Surgical site infection (SSI) occurs at a high rate after ileostomy closure. The effect of preventive negative-pressure wound therapy (NPWT) on SSI development in closed wounds remains controversial. We conducted a prospective multicenter study to evaluate the usefulness of preventive NPWT for SSI after ileostomy closure., Methods: From January 2018 to November 2018, 50 patients who underwent closure of ileostomy created after surgery for colorectal cancer participated in this study. An NPWT device was applied to each wound immediately after surgery and then treatment was continued for 3 days. The primary endpoint was 30-day SSI, and the secondary endpoints were the incidence of seroma, hematoma, and adverse events related to NPWT., Results: No patients developed SSI, seroma, or hematoma. Adverse events that may have been causally linked with NPWT were contact dermatitis in two patients and wound pain in one patient, and there were no cases of discontinuation or decompression of NPWT., Conclusion: The use of NPWT following ileostomy closure may be useful for reducing the development of SSI in colorectal cancer patients. This is a prospective multicenter pilot study and we are planning a comparative study based on these successful results., Trail Registration: Registration number: UMIN000032053 ( https://www.umin.ac.jp/ ).

Objective: Adjuvant Chemotherapy Trial of TS-1 for Colon Cancer (ACTS-CC), a randomised phase III trial, demonstrated that adjuvant therapy with S-1 for stage III colon cancer was non-inferior in 3-year disease-free survival (DFS) to that of tegafur-uracil plus leucovorin (UFT/LV). We updated DFS and overall survival (OS) and performed T x N subset analysis., Methods: A total of 1518 patients with curatively resected stage III colon cancer were randomly assigned to receive S-1 (80-120  mg/day on days 1-28 every 42 days, four courses) or UFT/LV (UFT: 300-600  mg/day and LV: 75  mg/day on days 1-28 every 35 days, five courses)., Results: The 5-year DFS rates of the S-1 and UFT/LV group were 70.2 % and 66.9 %, respectively (HR 0.88; 95%  CI 0.74 to 1.06; p=0.177), and non-inferiority of DFS was reconfirmed with a median of 63.5-month follow-up. The similarity of OS was also confirmed (HR 0.92; 95%  CI 0.72 to 1.17; p=0.488); 5-year OS rates of the S-1 and UFT/LV group were 86.0 % and 84.4 %, respectively. No significant interactions were identified between the major baseline characteristics and DFS of the S-1 and UFT/LV groups, except for histological type; S-1 was more favourable in patients with poorly differentiated adenocarcinoma. Patient outcomes were well separated by TNM-substages (IIIA/IIIB/IIIC). With the patients divided into 20 subsets by T and N factors, the DFS and OS rates of T3 and N1 subset, which accounted for 62 % of stage IIIB patients and 44 % of all studied subjects, were significantly better than those of the other subsets in stage IIIB and similar to those of stage IIIA., Conclusions: Adjuvant therapy of S-1 for stage III colon cancer was reconfirmed to be non-inferior in DFS to those of UFT/LV after long follow-up. No difference in OS was also demonstrated. T3N1 patients might be considered separately from other patients included in stage IIIB because of its favourable outcome., Trial Registration Number: NCT00660894., Competing Interests: Competing interests: MI has received honoraria from Taiho Pharmaceutical Co. Ltd., and Merck Serono Co. Ltd.; research funding from Taiho and Yakult Honsha Co. Ltd. KS received honoraria and research funding from Taiho Pharmaceutical Co. Ltd. and Chugai Pharmaceutical Co. Ltd. All remaining authors have declared no conflicts of interest.

Reconstruction of a remnant pancreas after middle pancreatectomy has generally been performed with a pancreaticoenterostomy. We report here two cases in which physiological reconstructive procedures were performed. The reconstructive procedures included pancreatic duct-to-duct anastomosis and parenchymal sutures with absorbable monofilament interrupted stitches. A pancreatic tube was inserted for decompression at the anastomotic site in both cases. The patients comprised one with pancreatic metastasis from renal cell carcinoma and another with a non-malignant insulinoma. The tumors were located in the pancreatic body. Although an International Study Group on Pancreatic Fistula classification grade B-pancreatic fistula was observed in each patient, they both resolved with conservative therapy. The pancreatic duct at the anastomosis site was patent in both cases, and no atrophic changes developed in the remnant pancreas in either patient. These outcomes confirmed that, in selected cases, this reconstructive procedure is safe and feasible for physiological reconstruction without involvement of the digestive tract.

Bacteria isolated from surgical infections during the period from April 2009 to March 2010 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 671 strains including 16 strains of Candida spp. were isolated from 174 (79.1%) of 220 patients with surgical infections. Four hundred and eleven strains were isolated from primary infections, and 244 strains were isolated from surgical site infection. From primary infections, anaerobic Gram-negative bacteria were predominant, followed by aerobic Gram-negative bacteria, while from surgical site infection aerobic Gram-positive bacteria were predominant, followed by anaerobic Gram-negative bacteria. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus spp. was highest, followed by Streptococcus spp., and Staphylococcus spp. in this order, from primary infections, while Enterococcus spp. was highest, followed by Staphylococcus spp. from surgical site infection. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae, Enterobacter cloacae and Pseudomonas aeruginosa, in this order, and from surgical site infection, E. coli was most predominantly isolated, followed by P. aeruginosa and E. cloacae. Among anaerobic Gram-positive bacteria, the isolation rate of Eggerthella lenta was the highest from primary infections, followed by Parvimonas micra, Streptococcus constellatus and Finegoldia magna, and from surgical site infection, E. lenta was most predominantly isolated. Among anaerobic Gram-negative bacteria, the isolation rate of Bilophila wadsworthia was the highest from primary infections, followed by Bacteroides fragilis, Bacteroides ovatus and Bacteroides thetaiotaomicron, and from surgical site infection, B. fragilis was most predominantly isolated, followed by B. ovatus, B. wadsworthia and B. thetaiotaomicron, in this order. In this series, we noticed no vancomycin-resistant Gram-positive cocci, nor multidrug-resistant P. aeruginosa. We should carefully follow up B. wadsworthia which was resistant to various antibiotics, and also Bacteroides spp. which was resistant to many beta-lactam antibiotics.

Bacteria isolated from infections in abdominal surgery during the period from April 2008 to March 2009 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 712 strains including 18 strains of Candida spp. were isolated from 173 (80.5%) of 215 patients with surgical infections. Three hundred and sixty-six strains were isolated from primary infections, and 346 strains were isolated from postoperative infections. From primary infections, anaerobic Gram-negative bacteria were predominant, followed by aerobic Gram-negative bacteria, while from postoperative infections aerobic Gram-positive bacteria were predominant, followed by anaerobic Gram-negative bacteria. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus spp. was highest, followed by Streptococcus spp., and Staphylococcus spp. in this order, from primary infections, while Enterococcus spp. was highest, followed by Staphylococcus spp. from postoperative infections. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae and Pseudomonas aeruginosa, in this order, and from postoperative infections, P aeruginosa was most predominantly isolated, followed by E. coli, Enterobacter cloacae, and K. pneumoniae. Among anaerobic Gram-positive bacteria, the isolation rate of Eggerthella lenta was the highest from primary infections, followed by Parvimonas micra, Streptococcus constellatus and Gemella morbillorum, and from postoperative infections, E. lenta was most predominantly isolated. Among anaerobic Gram-negative bacteria, the isolation rate of Bacteroides fragilis was the highest from primary infections, followed by Bacteroides thetaiotaomicron, Bacteroides ovatus and Bilophila wadsworthia, and from postoperative infections, B. fragilis was most predominantly isolated, followed by B. thetaiotaomicron, B. wadsworthia and B. ovatus, in this order. In this series, we noticed no vancomycin-resistant methicillin-resistant S. aureus, and Enterococcus spp., nor multidrug-resistant P aeruginosa. We should carefully follow up B. wadsworthia which was resistant to various antibiotics, and also Bacteroides spp. which was resistant to many beta-lactam antibiotics.

We report herein a case of a 64-year-old woman found to have anastomotic suture line recurrence of an early rectal carcinoma. The patient had undergone laparoscopy-assisted low anterior rectal resection for an early rectal carcinoma 2 years before the anastomotic site recurrence. A follow-up colonoscopy revealed an elevated lesion on the anastomotic suture line. The diagnosis of adenocarcinoma was confirmed by biopsy. The patient underwent a resection of the remnant rectum. Histological examination of the resected specimen showed that the anastomotic site recurrence might have been caused by intraluminal implantation from the primary rectal cancer. We speculate that intraluminal implantation might be caused by insufficient intraoperative rectal irrigation because of limited access often encountered in laparoscopic surgery. We propose that it is necessary to devise a method with which to perform sufficient intraoperative rectal irrigation in laparoscopic surgery for rectal carcinoma.

Laparoscopic procedures for pancreatic surgery have been significantly improved recently; however, the number of successful laparoscopic or laparoscopy-assisted pancreaticoduodenectomies (PDs) has been limited. The limitations could be attributed to the complexity of the reconstruction procedures under laparoscopic observations and the high incidence of critical morbidity with PDs. To overcome the shortcomings, we developed the first hand-assisted laparoscopic pylorus-preserving PD and, in this report, present the case of a patient with a low-grade malignant tumor on the pancreas head.

Background/aims: A total of 209 bacterial strains were isolated from patients with biliary infection in our department between January 1982 and December 2000., Methodology: Antimicrobial susceptibility tests were conducted to ascertain the presence of drug-resistant bacteria., Results: The breakdown of the 109 strains from the patients with primary biliary infections was as follows: 70 strains of gram-negative aerobic bacteria; 27 strains of gram-positive aerobic bacteria; 6 strains of gram-negative anaerobic bacteria; and 6 strains of gram-positive anaerobic bacteria. Among the 100 strains isolated from the patients with postoperative infection, the frequency of anaerobic bacteria was similar, but the frequency of gram-negative aerobic bacteria was lower at 55 strains, whereas frequency of gram-positive aerobic bacteria was higher at 36 strains. Of the 70 strains of gram-negative aerobic bacteria isolated from patients with primary biliary infection, the following four bacteria accounted for 75% of the total: Klebsiella pneumoniae, Escherichia coli, Enterobacter spp., and Pseudomonas aeruginosa., Conclusions: The frequencies of gram-negative aerobic bacteria were high among patients with primary biliary infection, while those of gram-positive aerobic bacteria were high among patients with postoperative biliary infection. Although VRE was not isolated, the frequency of MRSA was extremely high.

Pancreas-sparing duodenectomy (PSD), which allows preservation of the pancreas in its entirety, is a promising procedure for low-grade malignancies of the duodenum, the periampullary region, and the neighboring retroperitoneum. We report a case of recurrent retroperitoneal liposarcoma involving the second and third parts of the duodenum, which was extirpated using PSD, after a right hemicolectomy for tumor invasion of part of the colonic hepatic flexura. The Roux-en-Y jejunal limb was sutured to the duodenal bulb in an end-to-end fashion, and the biliary and pancreatic duct systems were reconstructed with end-to-side anastomoses, placing the jejunal limb distal to the bulbo-jejunostomy after a septoplasty to repair the adjacent pancreatic and biliary ducts. Because retroperitoneal liposarcoma has a low incidence of lymph node metastasis, pancreaticoduodenectomy may be inappropriate, especially if minimally extensive surgery can ensure organ preservation. Pancreas-sparing duodenectomy could be the most appropriate procedure for nonepithelial malignant tumors located around the duodenum distal to the pylorus, which have no involvement with the pancreatic parenchyma or periduodenal lymph nodes.

The management of biliary injuries after laparoscopic surgery presents a surgical challenge. We describe a promising method of biliary reconstruction with umbilical vein covering followed by end-to-end anastomosis. In the patient reported here, the umbilical vein was identified in the pedicled ligamentum teres, transected as if it were a sheet, and sutured, then covered ventrally to the anastomosed bile duct. This procedure may be a promising reinforcement of the reconstructed site which maintains the biliary integrity; however, it can be applied, only in selected situations.

Tendency of isolated bacteria from infections in general surgery during the period from April 2002 to March 2003 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 334 strains were isolated from 131 (75.3%) of 174 patients with surgical infections. One hundred and seventy-one strains were isolated from primary infections, and 163 strains were isolated from post-operative infections. From primary infections, anaerobic Gram-positive bacteria were predominant, while aerobic Gram-positive bacteria were predominant from postoperative infections. Among aerobic Gram-positive bacteria, although the isolation rate of Staphylococcus aureus was the highest, followed by that of Enterococcus faecalis from primary infections, the isolation rate of E. faecalis was the highest from postoperative infections. Among anaerobic Gram-positive bacteria, the isolation rate of Peptostreptococcus spp. was the highest from both types of infections. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae and Pseudomonas aeruginosa in this order, and from postoperative infections, E. coli was the most predominantly isolated, followed by P. aeruginosa, Enterobacter cloacae, and Citobacter freundii. Among anaerobic Gram-negative bacteria, the isolation rate of Bacteroides fragilis group was the highest from both types of infections. The isolation rate of aerobic Gram-negative bacteria from primary infections and that of aerobic Gram-positive bacteria from postoperative infections were high in the last several years. We noticed no vancomycin-resistant Gram-positive cocci nor P. aeruginosa producing metallo-beta-lactamase. But we noticed cefazolin-resistant E. coli probably producing extended spectrum beta-lactamase.

We describe a technique of rectal irrigation using an endo-bowel clamp (PL540S) in laparoscopy-assisted rectal resection. One of the major concerns associated with current techniques of laparoscopy-assisted rectal resection is accidental tumor spillage because it is difficult to perform the necessary procedures without grasping and manipulating the bowel and mesorectum near the tumor. Therefore, sufficient intraoperative rectal irrigation is essential for preventing intraluminal implantation of rectal cancer. However, this can be difficult, especially if the tumor is located in the rectum. By placing a PL540S before transection, it is possible to occlude the rectum completely and irrigate it effectively. We think that the PL540S is a valuable device in laparoscopic surgery for rectal cancer.

To investigate the contribution of beta-catenin to the development of gallbladder carcinoma, genetic alteration in beta-catenin gene, ctnnb-1 and subcellular localization of beta-catenin protein were searched. Mutational analysis of exon 3 in ctnnb-1, which encodes the serine/threonine residues for GSK3beta phosphorylation sites, was performed for 21 gallbladder carcinomas affected with/without the pancreaticobiliary malunion, PBM, and 6 non-cancerous tissues affected with PBM. We also analyzed subcellular localization of beta-catenin protein in all cases immunohistochemically. Nucleotide sequencing analysis revealed that none of them carried mutations that altered amino acid residues in the potential GSK3beta phophorylation sites, but one nucleotide substitution was found. We also analyzed subcellular localization of beta-catenin protein in all cases immunohistochemically, and confirmed its accumulation in both the nucleus and cytoplasm in 10 out of 21 cancer tissues, while the non-cancerous tissues which were affected with PBM and histologically diagnosed as hyperplasia or dysplasia displayed intense membranous staining. A significant correlation between cytoplasmic or nuclear beta-catenin immunoreactivity and clinicopathological status of gallbladder carcinomas was found, especially in the poorer histological differentiation grade(p < 0.05). In conclusion our results suggested that beta-catenin alteration might be a minor contributor to the development of gallbladder carcinomas through abnormal Wnt-wingless signalling, however, decreased membranous expression of beta-catenin might be correlated to carcinoma progression through loss of cell adhesive function in E-cadherin-catenin fashion.

Isolated bacteria from infections in general surgery during the period from April 2001 to March 2002 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, four hundred and twenty strains were isolated from 175 (79.2%) of 221 patients with surgical infections. One hundred and eighty-six strains were isolated from primary infections, and 234 strains were isolated from postoperative infections. From primary infections, anaerobic Gram-positive bacteria were predominant, while from postoperative infections, aerobic Gram-positive bacteria were predominant. Among aerobic Gram-positive bacteria, although the isolation rate of Staphylococcus aureus was the highest, followed by that of Enterococcus faecalis from primary infections, the isolation rate of E. faecalis was the highest from postoperative infections. Among anaerobic Gram-positive bacteria, the isolation rate of Peptostreptococcus spp. was the highest from both types of infections. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae and Pseudomonas aeruginosa in this order, and from postoperative infections, P. aeruginosa was the most predominantly isolated, followed by Enterobacter spp., E. coli and Klebsiella spp. Among anaerobic Gram-negative bacteria, the isolation rate of Bacteroides fragilis group was the highest from both types of infections. The isolation rate of aerobic Gram-negative bacteria from primary infections and that of aerobic Gram-positive bacteria from postoperative infections were high in the last several years. We noticed no vancomycin-resistant Gram-positive cocci.

Background/aims: Recently, we developed the method for measurement of the technetium-99m-diethylenetriamine-pentaacetic acid-galactosyl human serum albumin (Tc-GSA) receptor amount (R0) using a nonlinear 3-compartment model. We examined the usefulness of R0 for preoperative estimation of risk in hepatectomy., Methodology: Sixty-three patients who underwent hepatectomy in our hospital were examined for R0. These patients consisted of 26 cases of normal liver, 16 cases of liver fibrosis, and 21 cases of cirrhosis. R0 was measured by the nonlinear 3-compartment model of ligand-receptor binding without blood sampling in Tc-GSA scintigraphy. The expected remnant liver R0 after hepatectomy was calculated from CT volumetry before hepatectomy., Results: The preoperative mean R0 of liver was 15.8 +/- 3.8 mg for Z0, 13.8 +/- 3.9 mg for Z1, and 6.9 +/- 2.3 mg for Z2. R0 in Z2 was significantly lower than Z0 and Z1 (p < 0.0001). Every patient whose remnant liver R0 was over 5 mg tolerated hepatectomy without any postoperative complications. Among 63 cases, 5 patients developed postoperative complications (two liver failures, two postoperative jaundice and one hepatic coma), and remnant liver R0 of these patients were under 5 mg., Conclusions: From these results, it can be seen that R0 of remnant liver is a useful parameter to decide indication of hepatectomy and predict postoperative complications.

Background/purpose: There have, hitherto, been no anatomical investigations of the intramural venous system of the duodenum., Methods: Intramural longitudinal anastomoses of the straight veins in the human duodenum were investigated, using 15 latex resin cast specimens., Results: The venous tree (with a straight vein as the trunk) was developed well, with numerous twigs (venules). We identified two types of longitudinal anastomoses between the straight veins; the direct and plexus-mediated types, with an equal incidence. The direct-type anastomosis was 0.1-0.5 mm in minimum diameter along the course and communicated in almost a straight line between the mother straight veins. In contrast, the plexus-mediated type was regarded as the thickest route (almost 0.1 mm) in the suggested submucosal venular network in the duodenal wall. These two types of anastomoses were distributed almost equally in most of the duodenum, although a relatively lower density was found in the superior portion. On the ventral side of the duodenum, the thicker straight veins had anastomotic branches significantly more frequently than the thinner ones (P = 0.0018). CONCLUSIONS; These results seemed to support the feasibility of Kocher mobilization, as well as the conventional poor preservation of the duodenal venous system during duodenum-preserving surgery. However, because the intramural longitudinal venous anastomoses were limited in number and location, we recommend preservation of the posterior superior pancreaticoduodenal vein and either of the inferior venous arcades, in combination with their concomitant arteries, in exchange for the unavoidable sacrifice of Henle's trunk and the dorsal pancreatic vein.

Aim: To determine whether superparamagnetic iron oxide-enhanced magnetic resonance imaging (SPIO-MRI) could replace intravenous contrast-enhanced spiral CT (iv-CT) and spiral CT during arterial portography (CTAP) combined with spiral CT hepatic angiography (CTHA) in the diagnosis of liver metastases from colorectal carcinomas., Methods: Twenty-six adult patients with liver metastases were studied preoperatively by means of iv-CT, CTAP/CTHA, and SPIO-MRI. Preoperative diagnoses using iv-CT, CTAP/CTHA, and SPIO-MRI were compared with intraoperative and pathological findings in resected specimens. The gold standard for the lesions that were resected was histological examination. Intraoperative findings represented the gold standard for lesions that were not resected., Results: Twenty-six patients were found to have a total number of 43 liver metastases. The sensitivities of iv-CT, CTAP/CTHA, and SPIO-MRI were 74.4, 100, and 90.7%, respectively. SPIO-MRI was significantly superior to iv-CT (p < 0.05). The positive predictive values of iv-CT, CTAP/CTHA, and SPIO-MRI were 97.0, 91.5, and 100%, respectively. CTAP/CTHA yielded four false-positive lesions. In contrast, we detected no false-positive findings using SPIO-MRI., Conclusions: These results suggest that SPIO-MRI might not completely replace CTAP/CTHA, but could replace iv-CT in the diagnosis of liver metastases from colorectal carcinomas. It is thought that SPIO-MRI is a promising imaging modality for diagnosing liver metastases in patients with colorectal carcinoma because of its relatively high sensitivity and extremely high specificity., (Copyright 2003 S. Karger AG, Basel)

Tendency of isolated bacteria from infections in general surgery and their antimicrobial susceptibilities during the period from April 2000 to March 2001 were investigated in a multicenter study in Japan, and the following results were obtained. The number of cases investigated as objectives was 234 for one year. A total of 388 strains (136 strains from primary infections and 252 strains from postoperative infections) were isolated from 165 cases (70.5% of total cases). In primary infections, anaerobic Gram-positive bacteria were predominant, while from postoperative infections, aerobic Gram-positive bacteria were predominant. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus faecalis was the highest, followed by that of Staphylococcus aureus from postoperative infections. Among anaerobic Gram-positive bacteria, the isolation rate of Peptostreptococcus spp. was the highest from both types of infections. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae and Pseudomonas aeruginosa in this order, and from postoperative infections, P. aeruginosa was the most predominantly isolated, followed by Enterobacter spp. and Klebsiella spp. Among anaerobic Gram-negative bacteria, the isolation rate of Bacteroides fragilis group was the highest from both types of infections. There was no vancomycin-resistant S. aureus nor Enterococcus spp. Among anaerobic bacteria, there were many resistant strains against penicillins and cephems with MICs higher than 100 micrograms/ml, and the same trend was observed among other Bacteroides spp. and Prevotella spp.

The annual multicenter studies on isolated bacteria from infections in general surgery and their antimicrobial susceptibility have been conducted in Japan since July 1982. In this paper, the results obtained in the academic year 1999 (from April 1999 to March 2000) have been summarized. Two hundred seven cases were investigated, and 411 strains were isolated from 169 cases (81.6%). Of those strains, 184 and 227 strains were from primary infections and postoperative infections, respectively. In primary infections, the isolation rates of anaerobes, Streptococcus spp., and Escherichia coli were higher than in postoperative infections, while in postoperative infections, those of Gram-positive aerobes were higher than in primary infections. Staphylococcus aureus were most frequently isolated among Gram-positive aerobes, Peptostreptococcus prevotii among Gram-positive anaerobes, E. coli among Gram-negative aerobes, and Bacteroides fragilis among Gram-negative anaerobes. In primary infections, the percentage of Gram-negative aerobes, which gradually increased by the year 1998, decreased in the year 1999. The percentage of Gram-negative anaerobes increased, while that of Gram-negative bacteria was equivalent to that in the last year. In postoperative infections, the percentage of Gram-negative anaerobes, which continuously increased after the year 1990, decreased, while that of Gram-positive aerobes, which decreased in the last year, increased. Methicillin-resistant S. aureus accounted for 70.7% of S. aureus (41 strains). Either the number of strain or the percentage of MRSA decreased. The susceptibilities of E. coli and Klebsiella pneumoniae decreased against third and forth generation cephems, oxacephems, and monobactams. The susceptibilities of P. aeruginosa to carbapenems tend to decrease after the year 1997. S. aureus showed good susceptibilities to the tested drugs including arbekacin, vancomycin, and teicoplanin.

We report a case of recurrent hepatocellular carcinoma (HCC) successfully treated with a combination therapy of interferon-alpha (IFN-alpha) and 5-fluorouracil (5-FU), which was administered intravenously. A 49-year-old Japanese man who underwent a right hepatectomy for HCC developed tumor recurrence in the liver 19 months after surgery. Abdominal CT revealed multiple metastatic lesions in the liver. He received a combination therapy of 500 mg/day of 5-FU that was given intravenously by continuous infusion and 5 x 10(6) units of IFN-alpha, given three times weekly. The treatment resulted in a fall in serum PIVKA-II (protein induced by vitamin K antagonism) levels from 337 mAU/ml to 65 mAU/ml and disappearance of tumor stain in enhanced CT. 5-FU is usually administered by arterial infusion in a combination therapy of IFN-alpha and 5-FU. However, 5-FU infusion may be possible intravenously in the combination therapy of IFN-alpha and 5-FU for the treatment of advanced HCC.

Intraductal papillary mucinous tumor of the pancreas is commonly regarded as histopathologically low-grade malignancy. As yet, no fixed strategy of treatment for the advanced aged patient with intraductal papillary mucinous tumor exists. An 80-year-old woman was admitted to our hospital in July 1996 because of back pain due to pancreatitis. Examinations showed a widely opened orifice of the ampulla of Vater, the mural nodule in the cystic lesion of the pancreas uncus, and a mucinous plug in the diffusely dilated main pancreatic duct, so the patient was diagnosed as having intraductal papillary mucinous tumor in the pancratic head. However, in view of the patient's advanced age and the fact that intraductal papillary mucinous tumor is commonly regarded as a slow growing and histopathologically low-grade malignancy, we refrained from radical operation and selected the best supportive care. Four years subsequent to this, her symptoms became uncontrollable and she returned to our hospital. In consideration of her age, side-to-side pancreaticojejunostomy as minimally invasive surgery was employed. The postoperative course was uneventful. The symptoms, biochemical profiles and images improved and she was discharged from the hospital 28 days after the operation. No event has been observed in the patient for one year after operation. Surgical decompression is considered to be effective minimally invasive surgery for intraductal papillary mucinous tumor.

A 45-year-old man was suffering from abdominal pain and vomiting. He was admitted to our hospital with a diagnosis of ileus and obstructive jaundice. He had undergone Roux-en-Y anastomosis for choledocholithiasis 14 years earlier. A computed tomography scan revealed a dilated afferent loop and dilated intrahepatic bile duct. Upper gastrointestinal examination with contrast medium and percutaneous transhepatic cholangiography showed a high intestinal obstruction around the jejunojejunal anastomosis. The patient underwent laparotomy based on a diagnosis of obstructive jaundice due to ileus. During the operation, he was found to have internal herniation of the small bowel through a rent in the mesentery around the Roux-en-Y anastomosis for choledochojejunostomy. The hernia was reduced, and bowel resection was performed due to stenosis of the afferent loop. Jejunojejunal anastomosis was re-performed and the defect in the mesocolon was closed. Internal herniation after Roux-en-Y anastomosis is a rare sequela, but it should be recognized that this complication can occur after Roux-en-Y anastomosis. For prevention of internal herniation around the Roux-en-Y limb, secure closing of the mesenteric defects is important.

We treated a patient in whom low-dose irinotecan therapy was effective for the treatment of multiple lung metastases of cholangiocellular carcinoma after operation. The patient was a 50-year-old man. He underwent extended right hepatectomy for cholangiocellular carcinoma, and multiple lung metastases occurred 8 months after operation. For the treatment of lung metastases, low-dose irinotecan therapy (70 or 40 mg/week) was carried out. Eighteen months after the lung recurrence, he is still alive with a good quality of life, although the lung metastases have progressed. These results suggest that low-dose irinotecan therapy can be effective for lung metastases of cholangiocellular carcinoma.

To investigate the contribution of beta-catenin to the development of carcinoma of the ampulla of Vater, genetic alterations of beta-catenin gene, CTNNB-1 were searched. Mutational analysis of exon3 in CTNNB-1, which encodes the serine/threonine residues for GSK-3beta phosphorylation sites, was performed on 21 cases of carcinoma of the ampulla of Vater, by means of polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) followed by nucleotide sequencing. We found one deleted mutation at codon 32 to approximately 65 in one case of carcinoma of the ampulla of Vater. We also analyzed subcellular localization of beta-catenin protein in all cases immunohistochemically, and confirmed its accumulation in the nucleus in four cases including in a CTNNB-1 mutated one. This is the first study to show CTNNB-1 mutation and beta-catenin expression in carcinoma of the ampulla of Vater. These results suggested that abnormal Wnt-wingless signaling and in particular beta-catenin alteration caused accumulation of beta-catenin, which might partially contribute to the development of carcinoma of the ampulla of Vater.

The clinical significance of serum apolipoprotein A-1 levels as an indicator of hepatic protein synthesis after hepatectomy was investigated. A total of 50 patients who had undergone hepatectomy at our department from 1997 to 1999 were selected for this study. The serum levels of apolipoprotein A-1, indocyanine green dye retention at 15 minutes, lectin-cholesterol acyltransferase, prealbumin, and high-density lipoprotein cholesterol were measured in these patients preoperatively and on postoperative days 7 and 14. The type of hepatic resection conducted was partial resection in 13 cases, subsegmentectomy in 13 cases, segmentectomy in five cases, and bisegmentectomy in 19 cases. All the patients tolerated the operation, and none of the cases had any severe complications, such as liver failure. In most cases, the serum apolipoprotein A-1 levels decreased on postoperative day 7 and recovered by day 14. There were no significant differences in the changes in apolipoprotein A-1 levels between patients with the individual types of operative procedures. The serum apolipoprotein A-1 levels showed significant correlations with the serum high-density lipoprotein cholesterol, lectin-cholesterol acyltransferase and prealbumin levels on postoperative days 7 and 14; however, there was no significant correlation with the indocyanine green retention test. When the cases were divided into three groups according to the serum level of apolipoprotein A-1 on postoperative day 7 (group A: over 81 mg/dl, group B: 61-80 mg/dl, group C: under 60 mg/dl), the serum indocyanine green retention, prealbumin, lectin-cholesterol acyltransferase and high-density lipoprotein cholesterol levels in group C were significantly lower than those in group A on postoperative day 7. On the basis of these results, it is suggested that the pattern of changes in the serum apolipoprotein A-1 levels may be a good indicator of the hepatic protein synthetic ability during the perioperative period after hepatectomy.

We present herein a case of a 75-year-old Japanese man who had developed a pancreatic abscess 7 years after a longitudinal pancreatojejunostomy for chronic pancreatitis. The patient, a heavy drinker of alcohol, underwent surgical decompression of a ductal obstruction to relieve persistent abdominal pain due to severely calcifying chronic pancreatitis. After the surgery, he stopped drinking alcohol and was treated with insulin to control secondary diabetes mellitus. Thereafter, his symptoms disappeared. Seven years after the surgery, however, he was hospitalized due to obstructive jaundice, high-grade fever, and right hypochondria pain. Ultrasound and computed tomographic scans of the abdomen both disclosed a cystic mass, approximately 6 cm in size, in the pancreatic head. Magnetic resonance imaging strongly suggested a pancreatic abscess with necrotic fluid and debris. First, percutaneous transhepatic cholangiodrainage (PTCD) was done to treat the progressively obstructive jaundice. Subsequently, fine-needle aspiration of the pancreatic abscess was performed under ultrasound guidance. Enterococcus avium and Klebsiella oxytoca were revealed by culture of abscess aspirates. He was successfully cured by treatment with both appropriate antibiotic and continuous PTCD for the obstructive jaundice.