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Most of the diseases for which apheresis therapy is indicated are intractable and rare, and each patient has a different background and treatment course prior to apheresis therapy initiation. Therefore, it is difficult to conduct large-scale randomized controlled trials to secure high-quality evidence. Under such circumstances, the American Society for Apheresis (ASFA) issued its guidelines in 2007, which were repeatedly revised until the latest edition in 2019. The ASFA guidelines are comprehensive. However, in the United States, a centrifugal separation method is mainly used for apheresis, whereas the mainstream procedure in Japan is the membrane separation method. The target diseases and their backgrounds are different from those in Japan. Due to these differences, the direct adoption of the ASFA guidelines in Japanese practice creates various problems. One of the features of apheresis in Japan is the development of treatment methods using hollow-fiber devices such as double filtration plasmapheresis (DFPP) and selective plasma exchange and adsorption-type devices such as polymyxin B-immobilized endotoxin adsorption columns. Specialists in emergency medicine, hematology, collagen diseases/rheumatology, respiratory medicine, cardiovascular medicine, gastroenterology, neurology, nephrology, and dermatology who are familiar with apheresis therapy gathered for this guideline, which covers 86 diseases. In addition, since apheresis therapy involves not only physicians but also clinical engineers, nurses, dieticians, and many other medical professionals, this guideline was prepared in the form of a worksheet so that it can be easily understood at the bedside. Moreover, to the clinical purposes, this guideline is designed to summarize apheresis therapy in Japan and to disseminate and further develop Japanese apheresis technology to the world. As diagnostic and therapeutic techniques are constantly advancing, the guidelines need to be revised every few years. In order to ensure the high quality of apheresis therapy in Japan, both the Japanese Society for Apheresis Registry and the guidelines will be inseparable.

BackgroundReduced lower limb circumference due to sarcopenia in patients with type 2 diabetes mellitus (T2DM) could be a useful screening tool for arteriosclerosis. Hence, the objective of this study was to clarify the relation between lower limb circumference and other body composition factors, muscle strength, and patient characteristics,and the progression of arteriosclerosis in patients with T2DM. MethodsWe included114 patients with T2DM receiving outpatient care, and assessed body composition (lower limb circumferences including tibial rough surface-calf 26% [TRSC%]), muscle strength indicators, patient characteristics, clinical diabetic neuropathy status, and examined their associations with brachial–ankle pulse wave velocity (ba-PWV) using multiple regression analysis. Additionally, the severity of ba-PWV was classified into 1400 cm/s, 1650 cm/s, and 1963 cm/s to investigate their associations using logistic regression analysis. ResultsThe mean age was 63.12±11.96 years and participants had T2DM for 11.25±9.45 years. Body mass index (BMI), HbA1c, abnormal ankle reflex, and TRSC% were adopted in the multiple regression analysis with ba-PWV as the dependent variable. In the logistic regression analysis of ba-PWV divided by 1400 cm/s, an index of arteriosclerosis, BMI was adopted, and when divided by 1963 cm/s, a mortality risk index, BMI, abnormal ankle reflex, and TRSC% were adopted.ConclusionArteriosclerosis in patients with T2DM is associated with a decrease in lower limb circumference; TRSC% was independently associated with severe arteriosclerosis when ba-PWV was ≥1963 cm/s, which is an indicator of mortality risk. Thus, lower limb circumference in the form of TRSC% may reflect the progression of arteriosclerosis.

Infected acute necrotic collections (ANC) and walled-off necrosis (WON) of the pancreas are associated with high mortality. The difference in mortality between open necrosectomy and minimally invasive therapies in these patients remains unclear. This retrospective multicenter cohort study was conducted among 44 institutions in Japan from 2009 to 2013. Patients who had undergone invasive treatment for suspected infected ANC/WON were enrolled and classified into open necrosectomy and minimally invasive treatment (laparoscopic, percutaneous, and endoscopic) groups. The association of each treatment with mortality was evaluated and compared. Of 1159 patients with severe acute pancreatitis, 122 with suspected infected ANC or WON underwent the following treatments: open necrosectomy (33) and minimally invasive treatment (89), (laparoscopic three, percutaneous 49, endoscopic 37). Although the open necrosectomy group had a significantly higher mortality on univariate analysis (p = 0.047), multivariate analysis showed no significant associations between open necrosectomy or Charlson index and mortality (p = 0.29, p = 0.19, respectively). However, age (for each additional 10 years, p = 0.012, odds ratio [OR] 1.50, 95% confidence interval [CI] 1.09–2.06) and revised Atlanta criteria-severe (p = 0.001, OR 7.84, 95% CI 2.40–25.6) were significantly associated with mortality. In patients with acute pancreatitis and infected ANC/WON, age and revised Atlanta criteria-severe classification are significantly associated with mortality whereas open necrosectomy is not. The mortality risk for patients undergoing open necrosectomy and minimally invasive treatment does not differ significantly. Although minimally invasive surgery is generally preferred for patients with infected ANC/WON, open necrosectomy may be considered if clinically indicated.

Hemodialysis patients with diabetic kidney disease (DKD) experience blood glucose fluctuations owing to insulin removal. We evaluated the effects of single and long-term application of neuromuscular electrical stimulation (NMES) during hemodialysis on glycemic control. This trial was conducted in two stages: Stage 1, following a crossover design and 4 week washout period, eleven outpatients with DKD either underwent a single bout of NMES for 30 min (NMES period) or rested (control period) after receiving nutritional support during hemodialysis; Stage 2, following a crossover design and 4 week washout period, each participant received the intervention for 12 weeks. NMES was administered for 30 min at the maximum tolerable intensity. The mean subcutaneous glucose concentration and mean amplitude of glycemic excursion (MAGE) were determined by flash glucose monitoring for 24 h. Changes in glycoalbumin and MAGE before and after NMES initiation were evaluated. The mean blood glucose level and MAGE after a single bout of NMES were significantly lower than those after rest. Glycoalbumin levels and echo intensity of the rectus femoris tended to decrease, but not significantly by ANOVA due to a lack in statistical power after the dropout of three patients. NMES in end-stage DKD decreased blood glucose levels during and after hemodialysis.

Typical causes of infection in Crohn's disease (CD) patients include intra-abdominal abscess, microperforation of the intestine, and fistula formation. Use of immunosuppressive drugs and abdominal surgery are often associated with CD sepsis. In this case, an 11-year-old boy who did not receive any concomitant treatment was admitted for evaluation owing to weight loss. On the 22nd day of hospitalization, he suddenly experienced a septic shock and was admitted to the intensive care unit (ICU). Enterobacter cloacae was detected in the blood culture. No findings as to the source of the intra-abdominal infection were present. The patient was treated with antibiotics, ventilator management, circulatory management with massive intravenous fluids and vasoactive agents, and blood purification therapy. Suspecting the presence of CD based on weight loss and a history of perianal abscess two years prior, a lower gastrointestinal endoscopy was performed. The results revealed a longitudinal ulcer with skip lesions. His general condition was stabilized, and he was extubated on the seventh day in the ICU. He subsequently began treatment for CD in the general pediatric ward. In conclusion, when a sepsis on account of the intra-abdominal infection is suspected, but the infection focus is not evident and the immunosuppressive background is unclear, CD should be considered. Doing so will ensure that sepsis and CD are treated appropriately.

Renal artery pseudoaneurysms (RAPs) are a rare complication of percutaneous kidney biopsies that generally present as hematuria and back pain and are treated with angioembolization. A 60-year-old man was admitted to our emergency department for sudden left back pain. He was taking an oral anticoagulant for atrial fibrillation. He had undergone an ultrasound-guided percutaneous renal biopsy 26 days prior. We diagnosed him with hemorrhagic shock from the renal artery. Although he received a massive rapid blood transfusion, he went into cardiac arrest. Resuscitative endovascular balloon occlusion of the aorta (REBOA) was performed and, within 10 min, the patient achieved return of spontaneous circulation and regained consciousness. Subsequently, angioembolization was successfully performed for a 12.5 mm × 5.9 mm pseudoaneurysm in the left renal inferior pole close to the site of the renal biopsy. A total of 1680 mL of red blood cells and fresh frozen plasma were administered respectively until hemostasis was completed. He was then treated with continuous hemodialysis in the intensive care unit (ICU) for 6 days. He stayed in the ICU for 9 days and was moved to the general ward with full neurological recovery and a sufficiently stable condition to be able to walk. In conclusion, clinicians should be aware of the possibility of severe hemorrhagic shock due to RAPs after renal biopsy. Moreover, even if the patient goes into cardiac arrest, there is a possibility of full recovery if REBOA is performed and angioembolization is completed.

A 40-year-old man was admitted to the hospital with multiple injuries, including head injury and his laboratory results were significant for sodium abnormalities. Initially, hypernatremia was from increased sodium intake. Subsequently, hyponatremia developed that was unresponsive to sodium supplementation. Syndrome of inappropriate antidiuretic hormone secretion or cerebral salt wasting syndrome was suspected. Additional tests suggested post-traumatic hypopituitarism was responsible for the hyponatremia. Corticosteroid were given which normalized the serum sodium level, but the urine volume increased. Masked diabetes insipidus was suspected and desmopressin was given, stabilizing the serum sodium level. Recognizing the factors that cause sodium abnormalities in trauma patients can help lead to the correct diagnosis.

Infected acute necrotic collections (ANC) and walled-off necrosis (WON) of the pancreas are associated with high mortality. The difference in mortality between open necrosectomy and minimally invasive therapies in these patients remains unclear.This retrospective multicenter cohort study was conducted among 44 institutions in Japan from 2009 to 2013. Patients who had undergone invasive treatment for suspected infected ANC/WON were enrolled and classified into open necrosectomy and minimally invasive treatment (laparoscopic, percutaneous, and endoscopic) groups. The association of each treatment with mortality was evaluated and compared.Of 1159 patients with severe acute pancreatitis, 122 with suspected infected ANC or WON underwent the following treatments: open necrosectomy (33) and minimally invasive treatment (89), (laparoscopic three, percutaneous 49, endoscopic 37). Although the open necrosectomy group had a significantly higher mortality on univariate analysis (p = 0.047), multivariate analysis showed no significant associations between open necrosectomy or Charlson index and mortality (p = 0.29, p = 0.19, respectively). However, age (for each additional 10 years, p = 0.012, odds ratio [OR] 1.50, 95% confidence interval [CI] 1.09-2.06) and revised Atlanta criteria-severe (p = 0.001, OR 7.84, 95% CI 2.40-25.6) were significantly associated with mortality.In patients with acute pancreatitis and infected ANC/WON, age and revised Atlanta criteria-severe classification are significantly associated with mortality whereas open necrosectomy is not. The mortality risk for patients undergoing open necrosectomy and minimally invasive treatment does not differ significantly. Although minimally invasive surgery is generally preferred for patients with infected ANC/WON, open necrosectomy may be considered if clinically indicated.

Palladium-catalyzed intermolecular alkoxy-alkoxycarbonylation of vinylphenols under normal pressure of CO and O2 in alcohol was developed to afford the corresponding 3-alkoxy-3-arylpropanoates in good to high yields. Not only primary alcohols but also secondary alcohols were applicable to the present reaction. The presence of a tin salt was crucial to realize reproducibly high yields.

Desymmetrization of various meso-methylenecyclopropanes was accomplished by a palladium-catalyzed asymmetric ring-opening bis(alkoxycarbonylation) reaction employing a chiral bioxazoline ligand. The reaction proceeded smoothly in the presence of copper(I) triflate under carbon monoxide and oxygen at ambient pressure to give the corresponding optically active α-methyleneglutarates with up to 60% ee. Desymmetrization of protected meso-(3-methylenecyclopropane- 1,2-diyl)dimethanols was also carried out to give enantioenriched highly oxygen-functionalized α-methyleneglutarates. © 2014 Elsevier Ltd. All rights reserved.

Plasma diafiltration (PDF) is a blood purification therapy in which simple plasma exchange (PE) is performed using a selective membrane plasma separator while the dialysate flows outside the hollow fibers. A prospective, multicenter study was undertaken to evaluate the changes in bilirubin, IL-18, and cystatin C, as well as the 28-day and 90-day survival rates, with the use of PDF according to the level of severity as measured by the Model for End-Stage Liver Disease (MELD) score. Twenty-one patients with liver failure were studied: 10 patients had fulminant hepatitis and PDF therapies were performed 28 times; 11 had acute liver failure with the therapy performed 96 times. Levels of total bilirubin, IL-18, and cystatin C decreased significantly after treatment. The 28-day survival rate was 70.0% and that at 90 days was 16.7%. According to the severity of the MELD score, each of the results compared well with the use of Molecular Adsorbent Recirculating System or Prometheus therapy. In conclusion, PDF appears to be one of the most useful blood purification therapies for use in cases of acute liver failure in terms of medical economics and the removal of water-soluble and albumin-bound toxins.

Cross-conjugated azatrienes bearing an electron-withdrawing sulfonyl or benzoyl group on the nitrogen atom underwent, on heating or in the presence of a Lewis acid (TMSOTf), an initial inverse electron-demand hetero Diels–Alder reaction with electron-rich dienophiles (vinyl ether, vinyl thioether, and allenyl ether) to produce 1:1 cycloadducts with high endo selectivity. The initial cycloadducts thus obtained underwent a second Diels–Alder reaction stereoselectively on the newly formed diene unit with electron-deficient dienophiles to give the crossed bis-cycloadducts, octahydroquinolines, with high diastereo-π-facial selectivity. The N-sulfonylazatrienes tethering an ortho-cinnamyloxyphenyl dienophile at the triene terminal underwent an initial intramolecular hetero Diels–Alder reaction of the inverse electron-demand type. The subsequent second Diels–Alder reaction of the formed mono-cycloadducts completed the diene-transmissive hetero Diels–Alder protocol to give benzopyrano[3,4-c]quinolines in a highly stereoselective manner.

We report two cases of hypertriglyceridemic necrotizing pancreatitis treated by plasma exchange (PE). The outcome of each case was quite different according to the timing of PE. A 36 year old man presented with abdominal pain, and a diagnosis of severe acute pancreatitis was made. His serum triglyceride (TG) level was 6,460 mg/dl. He did not undergo PE at first, however, his condition never improved and PE was performed 20 days after the onset of his illness. Finally, he died of multiple organ failure and sepsis. In contrast, a 52 year old man with acute necrotizing pancreatitis was referred to our department. He received PE quickly after hospital admission. His serum TG level, which was 3,540 mg/dl at hospital admission, dramatically returned to normal limits, and he was discharged from the hospital 62 days after admission. The prognosis of severe necrotizing pancreatitis due to hypertriglyceridemia is extremely poor. PE should be applied for the treatment of hypertriglyceridemic necrotizing pancreatitis immediately after its onset.

症例は58歳,男性.便秘のため当院消化器内科を受診し脾腫瘍を指摘され入院.脾外に突出する直径4cmの充実性腫瘍で,腹部CT, MRIでは辺縁のみ造影され,腹部血管造影上淡い腫瘍濃染像あり.繊維型の過誤腫を疑い,自然破裂の報告もあることから手術適応と判断し,腹腔鏡下脾摘出術を施行した.脾下極腹側に直径5.6×4.3cmの脾外に突出する球形の腫瘍を認め,腹腔鏡下に摘出しえた.割面では充実性で正常脾実質との境界は鮮明だった.病理学特検索により,脾炎症性偽腫瘍と診断した.確定診断は術後の病理診断によるところが大きい脾炎症性偽腫瘍に対し,診断と治療を兼ねた腹腔鏡下脾摘術は低侵襲で有用と考えられた.

We report a case of gallbladder carcinoma associated with biliary obstruction and portal vein stenosis caused by massive lymph node metastases. The patient, a 59-year-old woman, was treated with self-expandable metallic stents — a spiral Z-stent in the portal vein, and a Wallstent in the bile duct — and intra-arterial infusion chemotherapy. She returned to work immediately after leaving the hospital, and has been treated with intra-arterial infusion chemotherapy once a week at our outpatient department. At present, she has good quality of life, with patency of both endoprostheses, 8 months after the placement of the metallic stents in the portal vein and the common bile duct. This case shows that portal vein and biliary stenting, together with intra-arterial infusion chemotherapy, can be an effective modality for the palliative treatment of advanced gallbladder carcinoma involving the portal vein and bile duct, to improve quality of life.

The initial inverse electron-demand hetero-Diels–Alder reaction of N-sulfonyldivinylmethanimine with electron-rich dienophiles (ethyl vinyl ether and ethyl vinyl sulfide) affords [4+2] cycloadducts with high endo selectivity. The monocycloadducts then undergo a second Diels–Alder reaction on the newly formed diene unit with electron-deficient dienophiles (tetracyanoethylene, 4-phenyl-1,2,4-triazoline-3,5-dione, and N-phenylmaleimide) to give highly stereoselectively the crossed biscycloadducts, hexa- and octahydroquinolines, and octahydropyridopyridazines.

Eight patients with pancreatic abscesses secondary to acute necrotizing pancreatitis underwent drainage of their abscesses under laparotomy. Two of them died of acute pulmonary thromboembolism (PTE) within 1 week. Autopsy revealed a large thrombus at the main trunk of the pulmonary artery and in the left common iliac vein. Femoral catheter insertion/indwelling, immobilization, surgery, increased trypsin/kinin/kallikrein, increased endotoxin, and decreased antithrombin-III (AT-III) were present following drainage of the pancreatic abscesses. With respect to the bedside diagnosis of acute PTE, alveolar-arterial oxygen gradients obtained by blood gas analysis and mean pulmonary artery pressure estimated by pulsed Doppler echocardiography are very useful. In terms of the treatment, attention should be paid to the following to prevent deep venous thrombosis: prophylactic administration of low molecular weight heparin and administration of AT-III (AT-III > or = 80%), use of the subclavian vein whenever possible as blood access for apheresis therapy, as short a compression time as possible after removing the blood access catheter (< or =6 h), and application of intermittent pneumatic compression devices or elastic compression stockings on the lower extremities.

Plasma diafiltration (PDF) is a blood purification therapy in which simple plasma exchange (PE) is performed using a selective membrane plasma separator while the dialysate flows outside the hollow fibers. A prospective, multicenter study was undertaken to evaluate the changes in bilirubin, IL-18, and cystatin C, as well as the 28-day and 90-day survival rates, with the use of PDF according to the level of severity as measured by the Model for End-Stage Liver Disease (MELD) score. Twenty-one patients with liver failure were studied: 10 patients had fulminant hepatitis and PDF therapies were performed 28 times; 11 had acute liver failure with the therapy performed 96 times. Levels of total bilirubin, IL-18, and cystatin C decreased significantly after treatment. The 28-day survival rate was 70.0% and that at 90 days was 16.7%. According to the severity of the MELD score, each of the results compared well with the use of Molecular Adsorbent Recirculating System or Prometheus therapy. In conclusion, PDF appears to be one of the most useful blood purification therapies for use in cases of acute liver failure in terms of medical economics and the removal of water-soluble and albumin-bound toxins.

Cross-conjugated azatrienes bearing an electron-withdrawing sulfonyl or benzoyl group on the nitrogen atom underwent, on heating or in the presence of a Lewis acid (TMSOTf), an initial inverse electron-demand hetero Diels–Alder reaction with electron-rich dienophiles (vinyl ether, vinyl thioether, and allenyl ether) to produce 1:1 cycloadducts with high endo selectivity. The initial cycloadducts thus obtained underwent a second Diels–Alder reaction stereoselectively on the newly formed diene unit with electron-deficient dienophiles to give the crossed bis-cycloadducts, octahydroquinolines, with high diastereo-π-facial selectivity. The N-sulfonylazatrienes tethering an ortho-cinnamyloxyphenyl dienophile at the triene terminal underwent an initial intramolecular hetero Diels–Alder reaction of the inverse electron-demand type. The subsequent second Diels–Alder reaction of the formed mono-cycloadducts completed the diene-transmissive hetero Diels–Alder protocol to give benzopyrano[3,4-c]quinolines in a highly stereoselective manner.

The initial inverse electron-demand hetero-Diels–Alder reaction of N-sulfonyldivinylmethanimine with electron-rich dienophiles (ethyl vinyl ether and ethyl vinyl sulfide) affords [4+2] cycloadducts with high endo selectivity. The monocycloadducts then undergo a second Diels–Alder reaction on the newly formed diene unit with electron-deficient dienophiles (tetracyanoethylene, 4-phenyl-1,2,4-triazoline-3,5-dione, and N-phenylmaleimide) to give highly stereoselectively the crossed biscycloadducts, hexa- and octahydroquinolines, and octahydropyridopyridazines.

手術侵襲の腹腔内臓器への影響をみるため, 開腹術を施行した胃癌, 胆道疾患, その他の疾患30例について, レーザードップラー血流計による術中の肝, 胃, 小腸組織血流量の変化を検索し, 術後肝機能異常との関係についても検討した. その結果, 肝組織血流量 (左葉) は, 胃亜全摘群 (n=6), 胃全摘群 (n=5), 胆道良性群 (n=9), 胆道悪性群 (n=5), その他の群 (n=5) で, それぞれ, 手術中に79.0%, 69.0%, 114.3%, 56.7%, 97.8%となり, 胃全摘群, 胆道悪性群で減少が著しかった.一方, 小腸組織血流量は, 各群でそれぞれ, 97.8%, 125.1%, 94.1%, 101.7%, 109.5%と維持されており, 門脈血流量が維持され, 肝動脈血流量が減少する間接的な所見と考えられた. トランスアミナーゼ値の変化では, 胆道悪性群, 一部の胆道良性群に高値を示し, 肝への圧迫操作が肝機能に悪影響を与えると考えられた.

門脈本幹の遮断による肝内血行動態の変化を明らかにするために,脾皮下固着ラットを用いて,門脈遮断後,経時的に門脈終末枝圧と中心静脈圧との変化をmicropuncture法によって測定し,肝組織血流量および求肝性副血行路の形成状態との関連癒検討した.門脈結紮により,門脈終末枝圧,門脈終末枝-中心静脈圧較差,肝組織血流量は低下したが,門脈終末枝圧,圧較差は結紮後4週で,肝組織血流量は同じく3日で対照値に復した.門脈造影では,門脈結紮1週後より求肝性副血行路の形成を認め,4週後で著明となり肝内門脈枝も明瞭に造影された.門脈終末枝圧,門脈終末枝-中心静脈圧較差の回復は求肝性副血行路形成の経過とよく相関したことから,結紮後早期に代償性の肝動脈血流量増加があり,4週では求肝性副血行路形成によって門脈血流量が回復するものと推測された.

The significance of drug regimen with AT-III preparation was studied by determining the changes in the blood coagulation system. In this study celiotomic patients complicated by cirrhosis in their perioperative periods were subjected, which consisted of 3 patients with hepatic, 2 with residual gastric, and 2 with sigmoid colonic cancers. The AT-III preparation was administered in a dose of 1, 500 units/day for 3 perioperative days, and AT-III activity, platelet count, HPT, FDP, D-dimer and fibrinogen were measured over time. As a result, AT-III activity increased after administration of AT-III for 3 perioperative days and was successfully maintained at more than 50% of the normal level in 6 out of the 7 cases. It was also possible to inhibit postoperative decreases in platelet counts.However, one case exhibited a decreased AT-III activity and died after complications of DIC. Thus, it was considered necessary to extend the perioperative period of administering AT-III to cirrhotic cases to maintain AT-III activity at more than 50% of the normal level.

Although bacterial translocation (BT) is thought to be a main cause of secondary pancreatic infection, the clinical significance is still unclear. Therefore, we investigated relationship between pancreatic infection and BT, analyzing the results of treatments such as continuous regional arterial infusion of protease inhibitor and antibiotics (CRAI), selective digestive decontamination, and early enteral nutrition (SDD/EN) in 45 severe acute pancreatitis patients. The infection rate of 17 cases without CRAI, SDD/EN was 58.8%, and mortality was 23.5%. Antibiotics-resistant bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA) was often proven in infected pancreatic tissue. Whereas, in 16 cases who underwent both therapy, only one patient died of multi-organ failure (6.3%). Pseudomonas aeruginosa and K. pneumoniae were proven from his feces before pancreatic infection coincidence, and, in autopsy, these bacteria and MRSA were proved from necrotic pancreatic tissue. BT must be large cause of secondary pancreas infection, because CRAI and SDD/ EN prevent secondary pancreatic infection. But we must consider other infection routes, and development of antibiotics resistant bacteria.

This study evaluated the usefulness of positron emission tomography with 2-deoxy-2-[18F]fluoro-D-glucose (FDG-PET) in monitoring the response to continuous arterial infusion chemotherapy (CAI) combined with external radiation therapy (ERT) for unresectable pancreatic carcinomas.Ten patients with unresectable pancreatic cancer were enrolled in this study. Computed tomography (CT) and FDG-PET were done before and after CAI (5-fluorouracil [FU], 500 mg/body per day) combined with ERT (50.4 Gy total dose). Tumor regression was evaluated by standardized uptake value (SUV) with FDG-PET, tumor size on CT, and changes in blood levels of carbohydrate antigen (CA) 19-9. The three methods of evaluation were compared.The ten patients were classified in three categories. In category I, tumor changes evident on CT and FDG-PET were consistent. In category II, CT could not accurately detect the area of the tumor. However, tumor uptake on FDG-PET decreased markedly after the treatment in category II patients. In category III, both CT and FDG-PET detected the tumor, as in category I. Although there was no definite change in tumor size on CT, FDG-PET uptake was markedly reduced immediately after the treatment. Reduction in tumor size did not appear on CT until 2 months later.FDG-PET aids in analysis of the effectiveness of chemotherapy and/or radiotherapy.

We report two patients with focal, chronic pancreatitis that was diagnosed by dynamic computed tomography (CT) combined with intraoperative biopsy. In case 1, serum carbohydrate antigen (CA) 19-9 level rose to 160 U/ml. Abdominal ultrasonography, CT, and magnetic resonance imaging demonstrated a mass, of 4.5 cm in diameter, in the pancreatic head. On dynamic CT, the mass was enhanced similarly to the normal pancreatic parenchyma. In case 2, dynamic CT demonstrated a mass, of 3.0 cm in diameter, in the pancreatic head, which was enhanced similarly to the normal pancreatic parenchyma. From such characteristics of enhancement, both masses were suspected to be chronic pancreatitis rather than cancer, and the diagnosis was confirmed by intraoperative biopsy. Three years in case 1 and 2 years in case 2 have passed since their operations, and the size of each mass has not changed. With the use of dynamic CT combined with intraoperative biopsy, focal chronic pancreatitis could be diagnosed more accurately, and this may lead to a reduction in unnecessary pancreatic resection.

We used positron emission tomography with 2-deoxy-2-[(18)F]fluoro- d-glucose (FDG-PET) in the diagnosis of two cases of malignant intraductal papillary mucinous tumor (IPMT) of the pancreas. A 56-year-old man and a 72-year-old man, both with tumors in the pancreatic head, were referred to Akita University Medical Center. Computed tomography revealed tumors with multiple cystic components in both patients. FDG-PET images showed markedly high FDG uptake in the area corresponding to a solid component found in one patient and diffuse faint uptake, higher than that of the surrounding tissue, in the other patient, who had no solid component. Histological examination of the resected specimens after pancreatectomy showed invasive carcinoma involving the pancreatic parenchyma in both patients. Although our experience is limited and preliminary, FDG-PET seems to be useful for the detection of malignancy in IPMT, especially in patients not showing any solid component on conventional diagnostic images such as computed tomography.

We herein describe a case of acute emphysematous cholecystitis in which the patient presented with symptoms of ileus. The patient was a 72-year-old man with no history of diabetes mellitus. He presented with epigastric pain, vomiting, and low-grade fever. Plain abdominal radiography showed some intestinal gas and niveau, and he was admitted to our hospital with a diagnosis of ileus. The next day, the abdominal pain increased and was accompanied by muscular defense. Plain radiography and computed tomography of the abdomen were carried out, and an emergency laparotomy was performed under a diagnosis of panperitonitis due to a perforation of the gallbladder caused by acute emphysematous cholecystitis. The patient made favorable progress after the operation and was discharged on postoperative day 14. Percutaneous transhepatic gallbladder drainage has been increasingly performed for the treatment of acute emphysematous cholecystitis, but when a perforation of the gallbladder is suspected, a laparotomy first should be considered.

The elimination of endotoxin by direct hemoperfusion over immobilized polymyxin B fiber (PMX-F) was carried out in two patients who developed septic shock associated with severe acute pancreatitis. Parameters such as blood pressure, body temperature, and plasma endotoxin level improved after PMX-F treatment, and the infected lesions were successfully and safely removed by surgery. Although an aggressive operative strategy of debridement with ultimate closure over drains is generally associated with low mortality in patients with this devastating disease, we often hesitate to perform this operation due to the poor condition of the patient in the acute period, with multiple organ failure and/or septic shock status, and also because of the difficulty in diagnosing the pancreatic infection. In this situation, endotoxin elimination using PMX-F is a useful tool for treating secondary pancreatic infections to help the patient recover in preparation for surgery, or for treating perioperative endotoxemia.

The induction of immunological tolerance by orthotopic liver transplantation (OLT) is donor-specific. Moreover, after the acceptance of a liver, other organs are not rejected. The aim of this study is to clarify characteristics of the prolonged islet survival as a result of immunological tolerance which was induced following simultaneous OLT.About 2000 islets were isolated from F344 rats. OLT was performed from F344 rats to diabetic LEW rats. Then the islets were transplanted into the transplanted F344 livers of diabetic LEW rats. Survival of the pancreatic islet allografts and deposits of IgM and IgG in the transplanted liver and islets were investigated.Survival time in the group with OLT (mean survival time: 46.4 +/- 38.2 days) was significantly longer than that without OLT (mean survival time: 8.1 +/- 0.8 days) (P0.01). Amount of serum antibody against donor lymphocytes was slightly higher in the group without OLT, and was very high in the group with OLT. Histologically, severe lymphocytic infiltration was observed in the Glisson's sheaths in the group with OLT. Islets were lodged, without lymphocytes inside, in small branches of the portal vein 7 days after transplantation. Immunohistologically, IgM and IgG deposits were found in the Glisson's sheaths and along sinusoids; however, they were not found in the islets.Induction of immunological tolerance and long-term survival of islets are possible by simultaneous OLT. The mechanism of this tolerance could be the host's selection of the liver as a target of preferred immunological attack.

The objective of this study was to develop an easy and simple experimental rat model of total hepatectomy, hepatic ischemia and extrahepatic portal obstruction. The first operation involved transposing the spleen with its scarified capsule in a subcutaneous pouch to produce portasystemic anastomosis. Total hepatectomy was easily performed in a lobe-by-lobe fashion 2 weeks following the first stage operation. Anhepatic rats receiving a glucose infusion survived for about 10 hours and all died of acute hepatic failure. Hepatic support systems can be accurately evaluated in this anhepatic rat model because of its uniformity. Sixty minutes of hepatic ischemia was able to be performed in rats with a transposed spleen for a portasystemic shunt and no complicated or technically involved procedure was required for the ischemic model. No rats died due to technical difficulties, suggesting the reliability and reproducibility of this ischemic model. An animal model resembling extrahepatic portal vein obstruction was also obtained by ligation of the portal vein; a simple maneuver which was able to produce collateral veins to the liver and cavernous transformation, as similarly seen in clinical patients with extrahepatic portal obstruction. Because these 3 animal models were so easily achieved in the rat, and since the changes in hepatic function and formation of the collaterals to the liver after portal vein occlusion are still poorly understood, this model should prove valuable for future study.