Search

Objectives We determined the outcomes of seton treatment through a series of techniques using biological agents (BIOs) in 18 patients with Crohn's disease (CD) who initially presented with perianal fistulas. Methods The patients underwent seton drainage using three seton types: a Penrose tube for fistulas with massive purulent discharge, a vessel loop for a small amount of discharge, and a rubber band for unproductive fistulas. If the distal end of the fistula extended more than 4 cm from the anal orifice, the skin and subcutaneous tissue were dissected along the outer edge of the anal sphincter to divide the fistulous tract into two portions. One seton encircled the sphincter from the primary opening throughout the anal canal (medial seton), and the other was inserted through the distal tract outside the sphincter (lateral seton). A BIO was then introduced immediately. When discharge ceased, the Penrose tube or vessel loop was replaced sequentially with a rubber band, which was tied fittingly and subsequently removed in medial to lateral order. Results The mean interval between fistula onset and CD diagnosis was 2.1 years, and that between CD diagnosis and introduction of BIOs was 0.5 years. The mean follow-up duration was 4 years. The BIOs currently used were infliximab in 10 patients, adalimumab in 7, and ustekinumab in 1. The overall success rate was 94.4%, including unproductive fistulas in 10 (55.6%) patients and fistula disappearance in 7 (38.9%). Conclusions Our seton drainage techniques via the "top-down" approach represent a promising avenue for treating perianal fistulas in patients with CD.

We present a case of a healthy 72-year-old man with herpes simplex hepatitis (HSVH) development soon after ordinary surgery for biliary stones. A sudden onset of hepatitis associated with high fever and leukopenia emerged on postoperative day 5, followed by a rapid and lethal course (died on day 9), despite an acyclovir therapy on day 8. Postmortem liver biopsy revealed positive immunostaining for herpes simplex virus (HSV) type-1. The serum tests (available after the death) were negative for anti-HSV immunogloblulins, but positive for HSV DNA. A review of 15 cases of postsurgical HSVH along with 42 cases of non-surgical HSH showed that (1): A wide spectrum of surgical procedures was involved; and (2): High mortality (87%) associated with lower rates of ante-mortem diagnosis (20%) and acyclovir treatment (20%). Due to the difficulty in diagnosis and lethal nature, an early clinical suspension and prompt empirical anti-viral intervention are imperative for postsurgical hepatitis with undetermined etiology, characterized by fever and leucopenia.

A 66-year-old man was admitted for severe acute alcoholic pancreatitis with infected pancreatic necrosis (IPN). Abdominal computed tomography revealed an inflamed pancreatic head, a dilated main pancreatic duct (MPD), and a large cavity with heterogeneous fluid containing gas adjacent to the pancreatic head, and extending to the pelvis. The cavity was drained percutaneously near the pancreatic head on admission; another tube was inserted into the pelvic cavity on hospital day 3. The drained fluid contained pus with high amylase concentration. Nasopancreatic drainage tube placement was unsuccessfully attempted on hospital day 9. On hospital day 23, percutaneous puncture of the MPD and placement of a pancreatic duct drainage tube was performed. Pancreatography revealed major extravasation from the pancreatic head. The IPN cavity receded; the percutaneous IPN drainage tube was removed on hospital day 58. On hospital day 83, the pancreatic drainage was changed to a transpapillary pancreatic stent, and the patient was discharged. Measuring the amylase concentration of peripancreatic fluid collections can aid in the diagnosis of pancreatic duct disruption; moreover, dual percutaneous necrotic cavity drainage plus pancreatic duct drainage may be essential for treating IPN. If transpapillary drainage tube placement is difficult, percutaneous pancreatic duct drainage may be feasible.

Background The development of pancreatic fistula (PF) associated with pancreatic necrosis is of great concern in the management of severe acute pancreatitis (SAP). We expected that early recognition and intervention of PF combined with percutaneous catheter drainage (PCD) for pancreatic infection may improve SAP outcomes. Methods Fifteen consecutive patients with SAP were enrolled. Whenever feasible, fine-needle aspiration for fluid collection was performed to determine infection and amylase concentration. For infection and PF with amylase-rich fluid, PCD and transpapillary endotherapy (preferably naso-pancreatic drainage) were carried out as soon as possible. PCD was intensively managed by irrigating the sized-up and multiple large bore catheters. Results Infected fluid collection and PF were both detected in 13 (86.7%) patients. Pancreatic duct (PD) disruption (n = 6) and organ failure (n = 5) occurred exclusively in patients with amylase-rich collection ≥10,000 U/L. The median timing of PCD and endotherapy was 15.5 and 16.5 days, respectively. No serious complications or mortality resulted from intervention procedures other than stent occlusion in one (6.7%) patient. Surgical intervention due to uncontrollable infection and visceral organ injury was avoided. Fistula closure was achieved in 12 (92.3%) of 13 PF patients with a median duration of 45 days. Disease-related mortality occurred in one (6.7%) patient. Conclusion Amylase-rich fluid collection ≥10,000 U/L may be an indication for further endoscopic investigation of PD disruption. Early dual drainage combining pancreatic endotherapy and PCD is feasible and safe, and may improve treatment outcome.

Backgrounds: Endoscopic ultrasonography (EUS) is used to observe the stricture of the main pancreatic duct (MPD) and in diagnosing pancreatic cancer (PC). We investigate the findings on EUS by referring to the histopathological findings of resected specimens. Materials and Methods: Six patients with carcinoma in situ (CIS) and 30 patients with invasive carcinoma of 20 mm or less were included. The preoperative EUS findings were classified as follows. A1: Simple stricture type—no findings around the stricture; A2: Hypoecho stricture type—localized hypoechoic area without demarcation around the stricture; A3: Tumor stricture type—tumor on the stricture; B: Dilation type—the dilation of the pancreatic duct without a downstream stricture; C: Parenchymal tumor type—tumor located apart from the MPD. Results: Classes A1 and A2 consisted of 2 CISs, and 4 invasive carcinomas included two cases smaller than 5 mm in diameter. Most of the cancers classified as A3 or C were of invasive carcinoma larger than 5 mm in diameter. All cancers classified as B involved CIS. Serial pancreatic-juice aspiration cytologic examination (SPACE) was selected for all types of cases, with a sensitivity of 92.0%, while EUS-guided fine needle aspiration cytology (EUS-FNA) was only useful for invasive carcinoma, and its sensitivity was 66.7%. Conclusions: Stricture without a tumor could be a finding for invasive PC and pancreatic duct dilation without a downstream stricture could be a finding indicative of CIS. Carcinoma smaller than 5 mm in diameter could not be recognized by EUS. SPACE had a high sensitivity for diagnosing small PC.

症例は77歳,女性.膵頭部癌の術前,血管造影を行ったところ,腹腔動脈は起始部(Celiac axis: CA)で挿管できず,拡張した膵アーケードを介して上腸間膜動脈より造影された. CTでは大動脈壁に石灰化が散在し, Three dimentional computed tomogra-phic amgiography (3D-CTA)では,正中弓状靱帯(MAL)による圧迫に特徴とされる“hooked appearance”は認められず,動脈硬化性のCA閉塞と診断した.しかし,術中, MALによる圧迫の解除のみでCA血流は再開した. 腹腔動脈起始部が閉塞し,膵頭十二指腸切除術を施行した英文報告39例を集計した.動脈硬化による閉塞は原則として血行再建を要し,一方, MALによる圧迫では, 11例中10例でMAL圧迫の解除のみで血流が再開したことから,閉塞の原因はその後の術式決定に重要であることが示唆された. MAL圧迫に特徴的な“hooked appearance”は呼気時に典型的に現れる.自験例では呼気時の画像で評価したため,正確な診断に至らなかったと思われた. 3D-CTAで閉塞原因を判定する際は,呼気時の画像で評価すべきである.

This study was carried out to clarify the etiology and clinicopathological features of hepatocellular carcinomas (HCCs) arising in patients without chronic viral infection or alcohol abuse.HCC patients who underwent resection were divided into three groups: a non-B non-C (NBNC) group (n = 13), who were seronegative for hepatitis B surface antigen (HBs Ag) and anti-hepatitis C antibody (HCV Ab), excluding a history of alcohol abuse; a B group (n = 25), who were seropositive for HBs Ag only; and a C group (n = 116), who were seropositive for HCV Ab only. We analyzed the features of tumor- and host-related factors and the outcome of the NBNC group.Hepatic inflammation and fibrosis were less severe in the NBNC group than in the other groups. There were no significant differences in tumor-related factors, except for higher serum levels of alpha-fetoprotein in the NBNC group. Recurrence rates and disease-free survivals were comparable among the three groups. The NBNC group comprised a greater population with one or two recurrent hepatic lesions (P0.05), and indocyanine green retention rates and fibrosis scores were preserved after the initial hepatectomy. The NBNC group had higher resection rates for intrahepatic recurrences (75.0%) than the other groups (21.1% and 22.2% in groups B and C, respectively; P0.05 and P0.05). The survival rate after the initial hepatectomy or detection of the recurrent lesions was significantly better in the NBNC group (both 100% at 5 years) than those in groups B and C (P0.05).NBNC patients maintained good liver function following the initial hepatectomy, and tended to have one or two recurrent lesions. These biological advantages provided NBNC patients more opportunities for repeat resection of intrahepatic recurrences, which may lead to a favorable outcome.

This retrospective study was designed to appraise the surgical procedures for pT2 gallbladder (GB) carcinomas. Twenty patients with pT2 GB carcinomas underwent surgical resection. Hepatectomy of segments 4b and 5 was performed in 19 patients, and an extended right hepatic lobectomy was performed in 1. The extrahepatic bile duct was preserved in 8 patients in whom the disease was limited to the GB fundus and/or body. Regional lymphadenectomy was performed in 18 patients. A separate radical second operation was performed in 8 patients after cholecystectomy. Final pathological staging was stage IB in 15 patients, IIB in 4, and IV in 1. Overall 5-year survival rate in those 20 patients was 77% without operative deaths. The 5-year survival rate in 5 patients with nodal metastasis and in 8 patients without extrahepatic biliary resection was 80% and 100%, respectively. A separate radical second operation in 8 patients yielded 75% survival after 5 years. Perineural invasion as a prognostic determinant was closely associated with tumor extending to the neck or the cystic duct. Partial hepatectomy, usually with extrahepatic biliary resection and regional lymphadenectomy, was appropriate as a standard radical operation for pT2 GB carcinoma, but preservation of extrahepatic bile duct is advocated for disease limited to the GB fundus and/or body. Radical second operation enhanced the chance for cure in patients with pT2 GB carcinoma.

PURPOSE: Disorder of mucosal immunity based on an imbalance between proinflammatory and anti-inflammatory cytokines is believed to be a major factor in the pathogenesis of ulcerative colitis. Platelet-activating factor potentially stimulates the production of proinflammatory cytokines and recruits inflammatory cells. The aim of this study was to determine whether and to what extent platelet-activating factor plays a role in the pathogenesis of ulcerative colitis. METHODS: Using dextran sulfate sodium-induced colitis in rats as a model of ulcerative colitis, we analyzed the composition of cellular infiltrates and the local tissue expression of messenger ribonucleic acid for cytokine-induced neutrophil chemoattractant and tumor necrosis factor-alpha. To directly assess the impact of platelet-activating factor on the development of colitis, we also determined the efficacy of a specific platelet-activating factor receptor antagonist for preventing dextran sulfate sodium-induced colitis. RESULTS: The activity of colitis was well correlated with the upregulation of cytokine-induced neutrophil chemoattractant and tumor necrosis factor-alpha messenger ribonucleic acid in local tissues and infiltration of cytokine-induced neutrophil chemoattractant-positive neutrophils and ED1-positive macrophages. The platelet-activating factor receptor antagonist effectively ameliorated colitis, along with causing a decrease in the tissue cytokine-induced neutrophil chemoattractant messenger ribonucleic acid level and a decline in neutrophil and macrophage infiltration. However, the antagonist did not alter tissue levels of tumor necrosis factor-alpha messenger ribonucleic acid. CONCLUSION: Platelet-activating factor plays a critical role in the pathogenesis of dextran sulfate sodium-induced colitis through recruitment of cytokine-induced neutrophil chemoattractant-positive neutrophils and macrophages and/or stimulation of cytokine-induced neutrophil chemoattractant release from activated neutrophils. The tissue level of tumor necrosis factor-alpha messenger ribonucleic acid does not closely reflect the activity of colitis.

We report herein a 5-year survivor after the resection of peritoneal metastases from pedunculated hepatocellular carcinoma (HCC). A 42-year-old man underwent lateral segmentectomy of the liver, with a diagnosis of pedunculated HCC, on October 10, 1994. The lesion was associated with intratumoral hemorrhage and was covered by the greater omentum, but there were no peritoneal metastases. The patient was readmitted to our hospital 4 months later with right upper quadrant pain. His serum alpha-fetoprotein level was 3ng/dl. Hepatitis B virus surface antigen (HBsAg) and hepatitis C virus antibody (HCV-Ab) were both negative. Abdominal computed tomography (CT) revealed two nodular lesions in the right upper abdominal cavity. He was diagnosed with peritoneal metastases from HCC. Because there were no other distant metastases, laparotomy was performed to resect these tumors. We found two other tumors, located in the mesentery of the appendix and ileum. All four tumors were resected by partial transverse colectomy and appendectomy. The histopathology of the tumors showed poorly differentiated HCC (Edmondson-Steiner's grade III). The patient has been doing well without recurrent disease for more than 5 years after the second operation. The prognosis of patients with pedunculated HCC is poor. Furthermore, resection for peritoneal metastases from HCC is rare because of the presence of multiple seeding in the abdominal cavity and distant organ metastases. To our knowledge, our patient is the longest survivor after resection of peritoneal metastases from pedunculated HCC.

The clinicopathological characteristics relevant to prognosis after surgical treatment of intrahepatic cholangiocarcinoma (ICC) remain unclear. In this study, the clinicopathological features of 19 patients with mass-forming ICC, the most common form of the disease, were reviewed to analyze prognostic determinants. Two or more segmentectomies of the liver with systematic lymphadenectomy were performed in 18 patients. Resection of the extrahepatic bile duct was performed in 14 patients, and reconstruction of the portal vein was accomplished in 5 patients. Stage IVA or IVB tumors were seen in 13 patients, and lymph node (LN) metastasis was present in 14 patients. The estimated 5-year survival rate after surgery for mass-forming ICC was 28%, with median survival time of 18 months. In univariate analysis, five variables were determined to be significantly correlated with poor survival of patients with mass-forming ICC after surgery. These variables include mass-forming ICC with periductal infiltration, perineural invasion, portal vein invasion, presence of intrahepatic metastasis, and two or more LN metastases. Survival rates of 5 patients without LN metastasis and 6 patients with a single LN metastasis were 80% and 33% at 5 years, respectively, while 8 patients with two or more LN metastasis failed to survive beyond 2 years. Multivariate analysis revealed the presence of intrahepatic metastasis to be an independent prognostic factor of poor survival. Hepatectomy with resection of the extrahepatic bile duct and systematic lymphadenectomy yields a good chance for prolonged survival for patients with mass-forming ICC when the lesion is singular and LN metastasis is limited to a regional LN. Because the presence of intrahepatic metastasis was closely related to a poor prognosis in patients with mass-forming ICC, efficacious chemotherapy would be needed to control development of the lesion.

We experienced an unusual case of duodenal adenocarcinoma associated with Peutz-Jeghers syndrome (PJS). A 34-year-old woman was admitted to our hospital with abdominal pain. She had been diagnosed as having PJS at 21 years of age, based on the presence of mucocutaneous pigmentation of the lip and fingertips, and colonic hamartomatous polyps. Abdominal computed tomography revealed a tumor in the third portion of the duodenum extending into the pancreas head. As the tumor was pathologically determined to be adenocarcinoma at the time of surgery, pylorus-preserving pancreaticoduodenectomy was performed. We carried out molecular analyses of this patient to examine the pathway of carcinogenesis in PJS. The tumor did not show somatic mutation of the APC and K-ras genes, which is a critical step for the adenoma-carcinoma sequence in colon cancer. Importantly, a germline mutation of the STK11 gene was detected at codon 281 delC in exon 6. Moreover, the tumor showed loss of heterozygosity of the 19p marker near STK11 and somatic mutation of the p53 gene. These findings suggest that STK11 is a tumor suppressor gene regulating the development of hamartomas, and that somatic mutation of p53 subsequently promotes gastrointestinal cancer at a later stage in PJS.

肝細胞癌に対するマイクロ波凝固療法(MCT)後に発生した気管支胆管瘻に対し,気管支鏡下処置により瘻孔閉鎖が得られた症例を経験したので報告する.症例は64歳の男性. 1990年に肝細胞癌に対し開胸開腹術による切除を受けた. 2001年3月21日,肝細胞癌(S6, S7)に対して開腹下MCTを施行した.術後23日目に肝膿瘍,横隔膜下膿瘍を発生し経皮的ドレナージを行った.瘻孔造影検査で胆汁瘻,気管支胆管瘻が確認されたが,肝膿瘍,胆汁瘻はドレナージおよび洗浄により消失した.しかし,気管支瘻が残存したため気管支鏡下に瘻孔内ブラッシングとフィブリン糊注入を行い, 8月27日に瘻孔は閉鎖された.全経過5カ月を要したが,退院後8カ月の現在肝細胞癌および気管支胆管瘻の再発はみられない.横隔膜直下の肝膿瘍に対するMCTは,開胸術の既往がある症例では術後の気管支瘻発生の危険性に留意する必要がある.

従来, 肝静脈を介して右心房にまで進展した肝癌は, 癌の末期的病変として切除適応外と考えられていた. しかし, 右心房腫瘍塞栓は右心不全および肺塞栓により, 突然死を引き起こす可能性があることから, 可及的に摘除を必要とする病態である. 症例は54歳の男性. 肝左葉を主座とし, 骨転移を伴う進行肝癌であったが, CTで中および左肝静脈より, 下大静脈および右心房に腫瘍栓を形成していることが発見された. 拡大肝左葉切除および体外循環下に心房腫瘍栓を摘除した. 術後33日目に退院し, 術後12か月経過した現在も生存中である. 肝細胞癌による右心房腫瘍栓の切除は, 自験例を含め, 本邦で18例が論文報告されている. 肝原発巣を含めた根治的腫瘍摘除が行われた13例中, 3例は2 年以上生存していることから, 心房に浸潤した進行肝癌に対しても, 肝内, 肝外転移のコントロールが可能であれば, 切除が推奨される.

Background Despite the well-recognized concordance of chimerism with spontaneous acceptance of rat liver allografts, the active role and the identity of chimeric cells mediating liver allograft tolerance are unknown. Because resting B cells are endowed with a tolerogenic antigen-presenting capacity, we assessed whether donor B cells propagated from the grafted liver may be responsible for liver allograft tolerance. Methods. Dark Agouti or Lewis rats were grafted with Lewis or Dark Agouti livers as a tolerogenic or a rejection combination, respectively. We followed the kinetics of donor B cells in recipients by flow cytometry, and we examined the fate of liver allografts depleted of passenger B cells in either B cell-sufficient or -deficient recipients. B-cell depletion was achieved by treatment of animals with polyclonal goat anti-rat IgM antibody from birth. Results. During the first 3 days after liver allografting, donor B cells rapidly migrated from graft-infiltrating cells and appeared in systemic circulation in both the tolerogenic and rejection combinations. However, systemic chimerism was detectable in the tolerogenic combination by day 14, whereas it was undetectable in the rejection combination by day 7. In graft-infiltrating cells, a significant expansion of chimeric IgM + (newly formed) B cells was observed on day 5 in the tolerogenic, but not in the rejection, combination. However, depletion of B cells from liver grafts and the absence of antibodies failed to alter the outcome of liver allograft survival in the tolerogenic or immunogenic combination. Conclusion. Although intragraft chimeric B cells proliferated in tolerogenic liver allografts, their clonal expansion does not seem to be essential for the promotion of liver allograft tolerance.

The linear perfluorinated poly(phenylene sulfide) [poly(thio-2,3,5,6-tetrafluoro-1,4-phenylene)] has been successfully prepared by polycondensation of 4-(methylsulfinyl)-2,3,5,6-tetrafluorophenyl 2...

Landslide blocks in a huge landslide have a fractal character. Their fractal dimension with respect to width averages 1.24 and with respect to length 1.44, Our limited data indicate that the fractal dimension is independent from the base rock geology. Huge landslides can be classified into first-, second-, and third-level blocks based mainly on the size of the blocks. Second- and third-level landslide blocks also have unique fractal dimensions. The fractal character of landslides can be explained by a) self-similar geometry and b) unique fractal dimensions made by combining second- and third-level blocks.

The majority of hepatocellular carcinomas are complicated by liver cirrhosis. Cirrhotic patients with a tumor located in segments 7 and 8 cannot tolerate right lobectomy. To perform curative resection without causing liver failure in such patients, resection of segments 7 and 8, together with resection of the right hepatic vein, is recommended. Nine patients underwent such resection. In four patients, the right hepatic vein was not reconstructed. One patient died of liver failure and the other two patients had postoperative liver dysfunction. Based on this experience, the right hepatic vein was reconstructed in the remaining five patients; the defect was repaired by transplanting a vein graft in three patients, and a patch graft was carried out in two. In one patient who underwent reconstruction with vein graft, veno-venous bypass was performed between the remnant hepatic vein and inferior vena cava. This procedure decompressed the remnant liver and facilitated secure anastomosis in reconstruction of the hepatic vein. There were no complications or deaths. The reconstructed veins were patent 2–3 years postoperatively. This procedure is feasible and valid, and should be widely practiced in patients with a diminished liver function reserve.

The purpose of this study was to determine the changes of hepatic sinusoidal endothelial cell (SEC) function in acute liver rejection with respect to receptor-mediated endocytosis. Orthotopic rat liver transplantation was performed in Lewis rats grafted with DA livers and in Lewis rats grafted with Lewis livers as rejectors and controls, respectively. Animals were killed at 1, 3, 5, 7, and 10 days after the operation. Fc receptors (FcRs) were histochemically stained on frozen liver sections by applying peroxidase-antiperoxidase IgG complex as a ligand, and the FcR activity, i.e., capacity of binding the ligands represented by the FcR staining intensity, was semiquantitatively analyzed as an indicator of SEC function. The serum level of hyaluronic acid, which is specifically cleared from the circulation by receptor-mediated SEC endocytosis, was also assayed, along with the total serum bilirubin. Three days after the operation, the SECs of rejectors showed a significantly weaker FcR staining intensity of about half the value of that seen in the controls (P < 0.05), and staining disappeared after 5 days (P < 0.01). The decrease of FcR staining intensity, i.e., FcR activity, showed a correlation with elevation of the serum hyaluronic acid level (r = -0.77; P < 0.001). Histological evidence of endothelialitis and a significant elevation of total serum bilirubin (P < 0.01) were also present at 3 and 5 days, respectively. These results suggest that impairment of the endocytic function of SECs occurs at an earlier phase of acute liver rejection when compared with development of abnormalities of traditional indicators. Determination of receptor-mediated SEC endocytic functions may thus provide useful information for the early diagnosis of acute rejection.

Hepatopancreatoduodenectomy (HPD) with hepatectomy has been widely employed for advanced biliary tract carcinomas. In this paper 10 patients with biliary tract carcinoma undergoing HPD with hepatectomy were compared with control groups for operative stress, hepatic regeneration, and postoperative complications. These 10 patients were divided into 2 groups, namely 6 undergoing resection of more than 2 segments and 4, less than 2 segments. Another each 10 patients undergoing extended hepatectomy or HPD were severed as control. HPD patients with hepatectomy of more than 2 segments showed significantly greater values in operative bleeding amount, operating time, and postoperative complications than those of other 3 groups. Postoperative total serum bilirubin significantly increased in HPD with hepatectomy (more than 2 segments) group. There were no differences in restoration of remnant hepatic volume after extended hepatic lobectomy with or without pancreatoduodenectomy. Median survival after HPD was 12 months. According to a questionnaire survey reported at the 16th Japan Pancreatectomy Society, the commonest cause of hospital deaths in HPD patients was hepatic failure, followed by preoperative T. Bil. level of 3mg/dl or more, age of over 60, hepatectomy of more than 2 segments, and association of vascular reconstruction, in this order (with significant difference). It is thought that an increase in total bilirubin well expresses a significantly severe operative stress with HPD than that with usual hepatectomy. Accordingly, HPD can escape associating with postoperative hepatic failure and other complications by an appropriate selection of operative candidates preceded by sufficient reduction of serum bilirubin; careful vascular reconstruction; and good nutritional management.

Gastric emphysema encompasses a broad spectrum of diseases. A 31-year-old woman presented with severe vomiting and epigastric pain. She had lost body weight for several months, and was later diagnosed as having anorexia nervosa. A radiological study demonstrated intramural gas with huge gastric dilatation and portal venous gas. She underwent total gastrectomy and was rescued from extensive gastric necrosis. Her clinical findings suggest that extraordinary dilation of the stomach increased the intraluminal pressure, thereby resulting in perfusion disturbance and extensive gastric necrosis. There are five other case reports of gastric emphysema associated with eating disorders in the literature. All but one were young women, and one of 4 patients with massive gastric necrosis died due to septic shock. Eating disorders cause gastric emphysema through several unique mechanisms, including gastric muscular atrophy, occlusion of the gastroesophageal junction, and delayed gastric emptying. Gastric emphysema in relation to eating disorders carries a risk of life-threatening complications and requires urgent diagnosis and treatment.

Hepatic resections were performed during the past 13 years on 31 patients with hepatic metastases from colorectal carcinoma. Of the 31 patients, 22 underwent lymph node dissection of the hepatic hilus. Ten patients underwent removal of recurrent lesions in the liver, lung, adrenal gland and brain after initial hepatic resection. The overall 5-year survival rate was 45 per cent. The outcome for six patients who underwent repeat hepatectomy after an initial hepatectomy was significantly better than for nine patients with unresectable recurrence (P < 0·01). Six of the 22 patients who underwent lymph node dissection had nodes positive for tumour. Two of the six patients underwent repeat hepatectomy and are alive after 49 and 66 months. Three- and 4-year survival rates of patients with positive lymph nodes were both 40 per cent. Repeat hepatectomy and dissection of hilar lymph nodes improves prognosis in selected patients with hepatic metastases of colorectal cancer.

Although hepatectomy for liver metastases from colorectal carcinoma is an effective treatment, recurrence in the liver is still the most common site after hepatectomy. Thirty patients underwent hepatectomy for hepatic metastases and 17 of them had recurrence in the remnant liver during the following 12-year period. Six of the 17 patients underwent a removal of isolated hepatic recurrences. Two of the six patients underwent a third hepatectomy, and three patients underwent partial lung resection on a total of five occasions. There were no operative deaths while complications after a third hepatectomy contributed to a high morbidity rate of 40 per cent. The mean length of survival of the six patients was 28.5 months from the second hepatectomy. The prognosis of the six patients who underwent a repeat hepatectomy was significantly better than that of patients with unresectable recurrence after an initial hepatectomy (p less than 0.01). The overall 5-year survival of 29 patients excluding one in-hospital death was 44.7 per cent. Our results reveal that aggressive removal of isolated and resectable recurrent disease has the potential to improve the prognosis of selected patients with metastatic cancer.

A 46 year old woman was admitted to our institute in June, 1987 with an attack of asthma, as well as remittent fever and leukocytosis accompanied by hypereosinophilia. She was found to have melena from an unknown source upon gastrointestinal examination. Four low-density areas were found in the liver on computed tomography and one of the intrahepatic foci formed a large extrahepatic abscess communicating with the intrahepatic duct on tubography. Resection of the four hepatic segments, including the large abscess, and cholecystectomy were performed. Healed necrotizing arteritis was histopathologically observed in the resected liver specimen, with the four low-density areas on CT scan having all been necrotic foci. One of them formed an intrahepatic biliary fistula and rupture of a hepatic aneurysm into a biliary duct was found to be the cause of melena. Although eosinophil infiltration and extravascular granuloma were not observed, a diagnosis of allergic granulomatous angiitis was made from the characteristic clinical course, systemic vasculitis and peripheral blood eosinophilia. To the best of our knowledge, this is the first report of intrahepatic duct perforation most probably being caused by hepatic aneurysm rupture in a patient with allergic granulomatous angiitis.

To clarify the pathobiology of the Fc receptors in the liver sinusoidal endothelium, the Fc receptors were studied by applying peroxidase-antiperoxidase IgG complexes as a ligand to frozen tissue sections from human cirrhotic livers, rat cirrhotic livers induced with CC14, rat regenerating livers after 70 per cent hepatectomy, livers of NZB/WF1 mice and livers of the mice injected intracutaneously with complete Freund's adjuvant (CFA). The Fc receptors showed a focal absence and the length of the Fc receptor-positive portions of the sinusoids in unit area decleased to about 50% and 60% of the normal value in the advanced cirrhosis in man and rats, respectively. The delayed blood clearance and decreased hepatic uptake of 125I-labeled BSA-antiBSA IgG comlexes were seen in the cirrhotic rats. The Fc receptor activity, estimated by staining intensity of the Fc receptors, was considerably decreased is the regenerating livers for 7 days after hepatectomy. The 5-week-to 9-month-old NZB/WF1 mice showed higher Fc receptor activity than control NZW mice. The Fc receptor activity in the CFA injected mice gradually increased until 4 week after administration. The hyperplasia or absence of Kupffer cell was found in these conditions, associated with increase and decrease of Fc receptor activity, but the causative relationship between Kupffer cell number and Fc receptor activity could not be found.

Classic polyarteritis nodosa (PAN) that targets medium-sized muscular arteries and microscopic polyangiitis (MPA), characterized by inflammation of small-caliber vessels and the presence of circulating myeloperoxidase anti-neutrophil cytoplasmic antibodies (MPO-ANCA), are distinct clinicopathological entities of systemic vasculitis. A 66-year-old woman presented with fever, cholestasis and positive MPO-ANCA. Radiological examination showed a pancreatic mass compressing the bile duct. Therefore, we performed pancreatoduodenectomy. Histopathological examination revealed that necrotizing vasculitis predominantly affecting the medium-sized vessels, spared arterioles or capillaries in the pancreas, a finding consistent with PAN. Unexpectedly, renal biopsy revealed small-caliber vasculitis and glomerulonephritis, supporting MPA. The initial manifestation of a pancreatic mass associated with vasculitis has only been reported in 7 articles. Its diagnosis is challenging because no reliable clinico-radiological findings have been observed. Clinicians should be aware of such cases and early diagnosis followed by immunosuppression is mandatory. Our findings may reflect a polyangiitis overlap syndrome coexisting between pancreatic PAN and renal MPA.

Papillary endothelial hyperplasia (PEH) is a reactive vascular lesion that was first described by Masson in 1923 [1]. This entity is believed to be an unusual form of organizing vascular thrombus, and is characterized by anastomosing vascular channels with endothelium-lined tufts and papilla-like formations [2]. Whereas PEH occurs commonly in the vessels of the systemic soft tissues, there have been only a few case reports of PEH in the visceral organs such as kidneys [3–5] and heart [6, 7]. Here we present a case of PEH in the liver, which provided pathological findings suggesting a unique pathogenesis of the disease.

Background Lymphocyte population constitutes major defense mechanism against endotoxemia, but the role of B lymphocytes in endotoxin-induced hepatic injury after hepatectomy is not clear. Methods We used lymphopenic (L(−)) rats by single administration of anti-rat lymphocyte serum, nu/nu athymic (T(−)) rats, B cell-ablated (B(−))rats by intermittent injection of anti-immunoglobulin (Ig) μ-chain from birth, and their vehicle controls. These animals were subjected to two-thirds hepatectomy with subsequent intravenous lipopolysaccharides (LPS, 1.5 mg/kg) administration. The survival rate, plasma alanine transaminase (ALT), tumor necrosis factor-α (TNF-α) and IgM levels, and total hemolytic activity (CH50) were determined. Hepatic tissue deposition of IgM or C3 was assessed with immunohistochemistry. Results The 24-h survival rate in control animals was 20%, whereas those in L(−), T(−), and B (−) animals were 80, 0, and 100%, respectively. Lymphocyte-sufficient control (L(+)) and B cell-sufficient control (B(+)) animals showed a rapid elevation of plasma TNF-α levels 1 h after the challenge, followed by an increase in plasma ALT levels. In B(+) group, plasma IgM levels were increased and CH50 activities were decreased 4 h after LPS injection with significant difference compared to those at time 0. Liver histology showed massive hepatic necrosis with a dense accumulation of IgM and C3 deposits 4 h after LPS administration. B cell ablation significantly ameliorated plasma ALT, IgM, and CH50 levels, showing less histological liver damage. Conclusion B lymphocytes susceptible to LPS might be implicated in the development of endotoxin-induced hepatic injury after partial hepatectomy.

A 12-year-old girl presented with hemoperitoneum caused by disseminated liver tumors accompanying a retroperitoneal germ cell tumor and was rescued by transcatheter hepatic arterial embolization. Following systemic chemotherapy, the liver tumors decreased in size and number, although the retroperitoneal tumor was resistant to therapy. We simultaneously resected the retroperitoneal tumor, and the liver lesions by extended left lobectomy combined with resection of the three major (right, middle, and left) hepatic veins, while preserving the inferior right hepatic vein. The postoperative course was uneventful, and liver regeneration evaluated by serial computed tomography was almost completed by three months following surgery. Pathological examination of the resected tumors revealed benign (mature) teratomas. Since complete removal of tumors critically influences the outcome in patients with mature teratoma, aggressive surgery is advocated for extensive tumors. The present case clearly demonstrated that extended hepatectomy with resection of three major hepatic veins is feasible and provides an opportunity for achieving complete remission in patients with metastatic germ cell tumor of the liver.

Background/Aims : This study was conducted to investigate the implication of Kupffer cells and the spleen in interleukin (IL)-10 production in endotoxin-induced liver injury after hepatectomy. Methods : Rats were divided into five groups: the S group, sham-operation; the SG group, sham-operation followed by intravenous gadolinium chloride (GdCl 3 : 7 mg/kg) administration to inhibit Kupffer cell function; the H group, two-thirds hepatectomy; the HG group, hepatectomy and subsequent GdCl 3 administration; the HGS group, hepatectomy and splenectomy with GdCl 3 administration. Lipopolysaccharide (1.5 mg/kg) was intravenously administered for each group 48 h after surgery. Results : GdCl 3 treatment significantly suppressed the elevation of plasma tumor necrosis factor (TNF)-α levels by lipopolysaccharide administration with completely inhibited induction of hepatic TNF-α and IL-10 mRNAs. In the HG group, marked increase in plasma IL-10 levels associated with enhanced splenic IL-10 mRNA was observed 1 h after lipopolysaccharide administration when compared to those in the H and HGS groups. Plasma TNF-α/IL-10 ratio 1 h after lipopolysaccharide administration was higher in the order of H, HGS and HG groups. Hepatic parenchymal damage and the 24-h mortality were lowest in group HG, followed by groups HGS and H. Conclusions : Kupffer cells after hepatectomy may aggravate endotoxin-induced liver injury via down-regulation of IL-10 production in the spleen.

This study was conducted to determine the influence of hepatic ischemia and reperfusion (HIR) injury on liver regeneration and the effect of the deletion variant of hepatocyte growth factor (dHGF) under these conditions. Male Sprague-Dawley rats were subjected to 60 minutes of total hepatic ischemia, and two-thirds hepatectomy was performed just before reperfusion. Animals received intravenous administration of either vehicle buffer (vehicle control group) or dHGF (1 mg/kg) (HGF group) at the end of the period of hepatic ischemia and again 6 hours after reperfusion. At 8 hours after hepatectomy, plasma HGF levels in the vehicle control group were significantly lower than those in the nonischemic controls. Plasma aspartate transaminase levels in the vehicle control group reached 3,462 +/- 1,039 IU/L, but levels in the HGF group were significantly inhibited to 1,849 +/- 605 IU/L. The relative liver weight in the vehicle control group was significantly greater than in the HGF group, a finding that was implicated in focal liver necrosis with sinusoidal congestion. Less histological damage was observed in the HGF group. Twenty-four hours after hepatectomy, an increase in the relative liver weight in nonischemic controls and in the HGF group was higher than that in vehicle control group, and the 5-bromo-2?deoxyuridine (BrdU) labeling index in the HGF group was 23% versus 18% in the nonischemic controls. Administration of dHGF significantly improved the 7-day survival to 82% versus 40% in the vehicle control group. dHGF has potential benefit as a pharmacological agent to ameliorate impairment of the hepatic microcirculation and to potentiate a regeneration response in the ischemically damaged liver after hepatectomy and/or liver transplantation.

Although liver resection is the accepted treatment for patients with metastatic colorectal cancer to the liver, there remains some controversy as to the criteria for patient selection and its impact on the recurrent disease following the operation. One hundred and sixteen patients underwent liver resection for metastaic colorectal carcinoma over the last 23 years at our institution. The actual survival was 50.5% at 5 years, and 38.6% at 10 years, excluding the 30-day operative mortality rate of 1.7%. Positive hepatic lymph nodes, extrahepatic disease, number of tumors (4 or more), and bilobar distribution of the diseases were strongly associated with poor outcome. These prognostic factors were also documented as the major prognostic determinants by 21 consecutive articles we reviewed. Among 52 (45.6%) patients with hepatic recurrence, patients who were acceptable surgical risks and had no extrahepatic diseases or a limited number (one or two) of lung metastasis were candidates for the repeat resection. Consequently, 31 patients underwent repeated hepatic resection. Their survival rate was 53.9% at 3 years and 32.3% at 5 years, with no mortality. This outcome is markedly better than that of untreated patients with an estimated survival of 3 to 24 months. Thus, an aggressive approach to surgical treatment is feasible with low risk and the potentially curative strategy even for recurrent hepatic metastases, providing the opportunity to achieve 5 year survival.

In order to achieve better results with hepatocellular carcinoma (HCC), repeated treatment using transcatheter hepatic arterial chemoembolization (TAE) with or without percutaneous ethanol injection (PEI) has been widely performed. A 73-year-old woman underwent a repeated (second) TAE two months following the primary TAE in combination with PEI. Prior to TAE, computed tomography (CT) with angiography revealed that the peripheral liver segment adjacent to the HCC was supplied exclusively via arterial flow without portal circulation. Following TAE, she developed an extrahepatic abscess with clinical and radiological evidence of ruptured HCC. A high-grade fever and right hypochondrial pain were sustained by day 10 after TAE, and CT showed a low-density mass extending into the subphrenic fluid collection. One hundred milliliters of infected fluid was drained by ultrasound-guided percutaneous aspiration from the collection. Following drainage, her clinical course was uneventful. Extrahepatic abscess formation is a rare complication of TAE, and, to our knowledge, only three cases of subphrenic abscess have been reported in the English literature. Severe ischemic necrosis of the arterial-feeding liver tissues devascularized by repeated TAE was considered to be a major contributor to this clinical condition. Early clinical suspicion combined with surgical management is mandatory in preventing serious morbidity of peritonitis accompanying repeated TAE.

Hepatic inflammatory pseudotumor (IPT) is a relatively rare lesion comprised of proliferating fibrovascular tissue infiltrated by inflammatory cells. IPT has a potential for recurrence and persistent local growth. We present a case of hepatic IPT mimicking a periductal-infiltrating type of intrahepatic cholangiocarcinoma (ICC) in a patient whose serum carbohydrate antigen 19-9 was slightly elevated. We performed a left hepatic lobectomy with resection of the extrahepatic bile duct and regional lymph node dissection under a preoperative diagnosis of ICC. However, histological examination of the resected tumor revealed granuloma tissue with lymphocyte infiltration, mainly by plasma cells, and proliferation into the surrounding connective tissue, and the lesion was ultimately diagnosed as hepatic IPT. This case points out the difficulties in differentiating between hepatic IPT extending along Glisson's sheath and ICC, based on imaging findings alone.

Type 1 diabetes is the result of a selective destruction of pancreatic islets by autoreactive T-cells. Therefore, in the context of islet or pancreas transplantation, newly transplanted beta-cells are threatened by both recurrent autoimmune and alloimmune responses in recipients with type 1 diabetes. In the present study, using spontaneously diabetic BB rats, we demonstrate that whereas isolated islets are susceptible to autoimmune recurrence and rejection, pancreaticoduodenal grafts are resistant to these biological processes. This resistance is mediated by lymphohematopoietic cells transplanted with the graft, since inactivation of these passenger cells by irradiation uniformly rendered the pancreaticoduodenal grafts susceptible to recurrent autoimmunity. We further studied the impact of local immunomodulation on autoimmune recurrence and rejection by ex vivo adenovirus-mediated CTLA4Ig gene transfer to pancreaticoduodenal grafts. Syngeneic DR-BB pancreaticoduodenal grafts transduced with AdmCTLA4Ig were rescued from recurrent autoimmunity. In fully histoincompatible LEW-->BB transplants, in which rejection and recurrence should be able to act synergistically, AdmCTLA4Ig transduced LEW-pancreaticoduodenal allografts enjoyed markedly prolonged survival in diabetic BB recipients. In situ reverse transcription-polymerase chain reaction revealed that transferred CTLA4Ig gene was strongly expressed in both endocrine and exocrine tissues on day 3. These results indicate the potential utility of local CD28-B7 costimulatory blockade for prevention of alloimmune and autoimmune destruction of pancreatic grafts in type 1 diabetic hosts.

This study investigated the release of endothelin (ET)-1 from the liver after warm ischemia/reperfusion (I/R) injury. Wistar rats were subjected to 120 min of warm hepatic ischemia by clamping the hepatic hilum under porto-jugular shunting. Reperfusion was performed by unclamping. The rats were divided into 2 groups receiving intravenous treatment with an anti-ET-1 mAb before ischemia (AET group) and with mouse immunoglobulin G (sham group). Hepatic blood flow was assessed by laser-Doppler flowmetry and reflectance spectrophotometry and was compared between the 2 groups along with the bile flow rate. The ET-1 concentrations of hepatic venous and portal blood were determined in the sham group, and the portal blood endotoxin levels were assayed in both groups. Both groups developed transient hypotension after reperfusion, but hepatic blood flow subsequently showed a significant improvement in the AET group. Hepatic congestion was detected in the sham group by both reflectance spectrophotometry and histological examination. After reperfusion, bile flow was significantly greater in the AET group. The portal endotoxin concentration showed no increase in both groups, and the hepatic venous blood ET-1 level in the sham group was significantly higher until 3 hr after reperfusion compared to the portal blood level. The 30-day survival rate was 50% in the AET group, whereas all the sham rats died within 12 hr. ET-1 was released from the liver after I/R injury and apparently participated in systemic and local hemodynamic changes that affected survival.

Objective: To assess the effectiveness of hepatopancreatoduodenectomy (HPD) in patients with advanced gallbladder carcinoma directly invading the liver and pancreas, generally considered to be nonresectable. Patients and Methods: Sixty patients with gallbladder carcinoma admitted to our hospital from 1978 to 1992, of whom 55 had Nevin stage V carcinoma and 21 had resectable tumors. Of these patients, seven underwent HPD. The remaining 34 patients had nonresectable tumors. The outcomes of patients undergoing HPD and those with nonresectable tumors were compared and the effect on their quality of life was also analyzed. Results: Postoperative complications occurred in five of the seven patients after HPD, but there were no operative deaths. The 1- and 2-year survival rates were 57% and 28.6%, respectively, with a median survival time of 12 months. In contrast, the 1- and 2-year survival rates of the 34 patients with nonresectable tumors were both 5.8%, and the median survival time was 2 months. The median and mean durations of home stay after HPD were 6 and 10.5 months, respectively. Conclusion: Hepatopancreatoduodenectomy has the potential to improve both survival and the quality of life for carefully selected patients with advanced gallbladder carcinoma. (Arch Surg. 1994;129:625-629)

Since 1978, we have performed extensive resection for recurrent carcinoma after initial hepatectomy for liver metastasis of colorectal carcinoma. Twenty-five patients had recurrence of carcinoma, and 14 of them had a resectable metastatic tumor. Eight patients with hepatic metastases underwent repeat hepatectomy on 11 occasions, and 8 patients, who had lung metastases underwent partial pulmonary resection on 11 occasions. Two patients underwent brain resection on 3 occasions, and one patient underwent right adrenalectomy combined with grafting of a 4.5-cm segment of the inferior vena cava. Results after surgery were compared with those obtained in 11 patients with nonresectable recurrent carcinoma. There were no operative deaths. The 5-year survival rate after initial hepatectomy in patients undergoing repeat hepatectomy, and pulmonary resection was 42.9 % and 37.5 %, respectively. Thus, surgical treatment of recurrence after hepatectomy achieved a significant improvement of survival compared with patients who had nonresectable recurrence (p

Portal vein thrombosis (PVT) after splenectomy in a patient with portal hypertension occurs with unusually high frequency. Recently, two patients with PVT following splenectomy were treated by fibrinolytic therapy with an enormous dosage of urokinase (UK) in a short period. PVT was quickly dissolved without side effects and the patients are now doing well without any recurrence of PVT. Therefore, when there is no evidence of bowel infarction, fibrinolytic therapy with an enormous dosage of UK over a short period is deemed to be both effective and essential as a conservative therapy for PVT.