Ultrasonic Cleaning for Irrigating Purulent Substances during Laparoscopic Gastrointestinal Surgery.

To improve the outcome of laparoscopic gastrointestinal surgery, improvement in the technology for removing purulent substances from the abdominal cavity is required. Ultrasonic cleaning technology may be suitable for the task. However, it is necessary to examine cleaning efficiency and safety through model tests that can lead to clinical trials for practical use. Nine surgical specialists first estimated the distribution of the actual attachment of purulent substances using videos of removing pus-like model dirt as an evaluation scale. Subsequently, cleaning tests were conducted using a small-size shower with model dirt that was somewhat difficult to remove, and its suitability as a model sample was confirmed. A mixture of miso and other substances was attached to a silicon sheet to prepare a test sample. The model dirt could be removed within a few seconds by cleaning using a probe-type ultrasonic homogenizer while the test sample was submerged in water. This performance greatly surpassed that of water flow cleaning under increased water pressure. An ultrasonic cleaner that is useful for irrigation during laparoscopic surgery will be suitable for practical use in laparoscopic surgery.

[A Case of Intrahepatic Cholangiocarcinoma Confused with a Recurrent Hepatocellular Carcinoma Treated by RFA at Diagnosis].

Intrahepatic cholangiocarcinoma(ICC)is the second most common malignant liver tumor after hepatocellular carcinoma (HCC). ICC is usually ischemic; however, it has variable findings and may be difficult to differentiate from HCC. We report about a case of ICC that was difficult to distinguish from HCC treated by radiofrequency ablation(RFA). A 79‒year‒old woman underwent RFA for HCC of the caudate lobe. Two years after RFA, a spindle‒shaped tumor was identified near the previous treatment site using contrast‒enhanced MRI. Images showed posterior segment bile duct dilation, posterior segment atrophy of the liver parenchyma, and posterior segmental portal vein disruption. We performed surgery because of the suspicion of a recurrent HCC invading into the bile duct. Intraoperative findings showed posterior segment atrophy. Intraoperative echocardiography could not identify the tumor but revealed a tumor plug and portal vein disruption in the posterior segment. The patient underwent post‒enlargement segmentectomy, caudate lobectomy of the liver, and biliary neoplastic resection. Histopathological findings showed no malignant findings in the hepatocytes. A moderately differentiated adenocarcinoma was found in the expanded bile duct, which was diagnosed as an intrahepatic cholangiocarcinoma. Here, we report about the case along with a discussion and a bibliographical consideration.

[A Case of Internal Hernia into a Reconstructed Pelvic Floor and Torsion of Jejunum near the Treitz Ligament after Laparoscopic Abdominoperineal Resection].

A 50s women underwent laparoscopic abdominoperineal resection(APR)for rectal cancer. Laparotomy was performed on the 8th postoperative day because of intestinal obstruction. An internal hernia was observed at the pelvic floor and the hernia orifice was found at the retroperitoneum that was sutured in the initial operation. On the other hand, the jejunum near the Treitz ligament was twisted, resulting in ischemic necrosis. The reason of the internal hernia is considered that a suction drain placed during the initial operation may have caused the rupture of the fragile part of the sutured peritoneum. Furthermore, increase of intra-abdominal pressure due to the internal hernia may have exacerbated the torsion of the jejunum near the Treitz ligament. This is probably due to the failure to the adequate reposition of the small intestine at the end of the initial operation. There is no consensus of the need for retroperitoneal sutures for APR. Currently, we only spray anti-adhesion agents on the pelvic floor without retroperitoneal reconstruction. Although the mobilization of small intestine is important to provide a good operative view in laparoscopic colorectal surgery, it is also important to confirm the reposition of the small intestine at the end of surgery.

An Experimental Study of the Effects of IABP on Coronary Artery Bypass Graft Flow Waveform.

PURPOSE: Graft evaluation after coronary artery bypass grafting (CABG) is still not sufficient. This study analyzed the flow waveform of coronary arteries and grafts during intra-aortic balloon pumping (IABP) assist. METHODS: Subjects were eight pigs that underwent off-pump CABG. Using transit-time flow measurement (TTFM) and occluder, blood flow waveforms were recorded while changing the degree of stenosis of Seg.6 and the left internal thoracic artery (LITA) and analyzed by percentage of reverse flow component to the total blood flow (R/T) and the ratio of diastolic blood flow of IABP operative and IABP inoperative (D1/D0). RESULT: Reverse flow of the LITA was reduced when stenosis of Seg.6 increased and R/T decreased. The average diastolic blood flow of Seg.8 and the LITA increased with IABP on showing a D1/D0 of 1 or more. R/T of the LITA increased when stenosis of Seg.6 was fixed and increasing the degree of LITA stenosis. D1/D0 increased up to a 75% LITA stenosis and is decreased in more severe stenosis. CONCLUSION: R/T is significantly higher in the antagonist or stenosis during IABP assist and was able to confirm the effectiveness of the graft as a functional assessment of graft. D1/D0 is useful as an indicator of the effectiveness of IABP on coronary blood flow.

[Gastric Complications in Stomach-Preserving Procedures on Total Pancreatectomy].

Whether the stomach should be preserved during total pancreatectomy(TP)is controversial. Therefore, we examined the correlation between stomach-preserving procedures on TP and postoperative gastric complications. Seven consecutive cases underwent TP(standard TP: 1 case, SSPTP: 3 cases, PPTP: 3 cases)for pancreatic cancer during the time period 2011-2019 at our hospital. There was no clinical case of postoperative gastric ulcer nor bleeding. Delayed gastric emptying(DGE)was observed in 4 cases of Grade A and 2 cases of Grade C. One of the Grade C cases was considered to be secondary DGE due to postoperative intestinal necrosis. The other was SSPTP case whose left gastric artery(LGA)was ligated. The patient had difficulty of food intake after the surgery and gastrointestinal endoscopy showed widespread hemorrhage and erosion of the gastric mucosa, considered to be ischemic gastropathy. Regarding primary DGE, most of cases were within Grade A even in stomach-preserving cases. Whereas, stomach-preserving procedure should be avoided when the LGA is ligated, because ischemic gastropathy may occur.

[Adenosquamous Carcinoma in the Remnant Pancreas after Pancreatoduodenectomy for Invasive Pancreas Cancer-A Resected Case with Five-Year Relapse-Free Survival].

A 52-year-old man underwent pancreatoduodenectomy(PD)for invasive cancer of the pancreatic head, with a histopathological diagnosis of moderately to poorly differentiated invasive ductal carcinoma. One year and 2 months after PD, follow- up CT revealed a mass 3 cm in diameter in the remnant pancreas without distant metastasis. Therefore, total remnant pancreatectomy was performed with a histopathological diagnosis of adenosquamous carcinoma. Five years after re-excision, the patient remains alive without recurrence. Although no tumor component was found at the anastomotic site of the pancreatojejunostomy, squamous metaplasia with chronic inflammation with carcinogenic potential was diffusely observed in the main pancreatic duct. Clinical cases of remnant pancreatic resection after PD for invasive cancer are relatively rare. Furthermore, this case of adenosquamous carcinoma with long-term recurrence-free survival is extremely rare.

[A Rare Case of Gastric Metastasis from Cholangio Carcinoma].

An 80-year-old man was referred to our hospital because of jaundice and fatigue. Abdominal computed tomography(CT) scan revealed an extrahepatic bile duct tumor, and biliary cytology detected adenocarcinoma; therefore, subtotal stomachpreserving pancreaticoduodenectomy was performed. Histological analysis showed that the tumor was a well-differentiated adenocarcinoma without lymph node metastasis. Two years after the initial surgery, blood examination detected an elevated serum CA19-9 level and submucosal tumor which is 2.5 cm diameter with an ulcer at the gastrojejunostomy anastomosis. Tumor biopsy was performed, and histological analysis revealed a recurrent cholangiocarcinoma. The tumor directly invaded the transverse colon mesentery; therefore, distal gastrectomy and right hemicolectomy were performed. The patient survived 12 months postoperatively without recurrence. Gastric metastasis from cholangiocarcinoma rarely occurs. Intraoperative exposure of bile juice may have caused gastric metastasis in this case.

[A Case of Pancreatic Mixed Acinar-Neuroendocrine Carcinoma with Main Pancreatic Duct Development].

A 78-year-old man was referred to our hospital owing to a pancreatic tumor detected on ultrasonography. He showed weight loss, and his diabetes mellitus had worsened over 3 months. Abdominal contrast-enhanced computed tomography revealed a 3 cm diameter pancreatic head tumor with peripheral enhancement and a dilated pancreatic duct. He underwent subtotal stomach-preserving pancreaticoduodenectomy. Examination of intraoperative frozen sections did not indicate cancer involvement at the edge of the resected pancreatic duct. The tumor was histologically diagnosed as mixed acinar-neuroendocrine carcinoma(MANEC). It was mainly detected in the pancreatic head and was accompanied by intra-ductal growth in the pancreatic duct. The patient has survived for 21 months without recurrence. MANEC is a rare disease associated with intraductal growth. Intraoperative diagnosis of tumor involvement at the edge of the pancreatic duct may be useful for R0 resection in surgery for MANEC.

[Severe Therapy-Related Pancytopenia Caused by UFT and LV in a Patient with Ascending Colon Cancer].

We report a case of a 79-year-old man who developed severe therapy-related pancytopenia from tegafur uracil(UFT)and Leucovorin(LV)as adjuvant chemotherapy for ascending colon cancer. Laparoscopic right hemicolectomy resection was performed for the ascending colon cancer. Pathohistological analysis revealed that the ascending colon tumor was moderately differentiated tubular adenocarcinoma(T3, N1, M0, and Stage III a). Postoperative adjuvant chemotherapy with UFT and LV was administered. After 2 courses of chemotherapies, severe thrombocytopenia(Grade 4)and neutropenia(Grade 4)were noted. Platelet and granulocyte-colony stimulating factor(G-CSF)were transfused. Furthermore, red blood cell transfusions were given for anemia(Grade 3). Dihydropyrimidine dehydrogenase(DPD)deficiency was suspected as the cause of the pancytopenia, and the ratio of dihydrouracil(DHU)and uracil(URA)was measured. However, the result was negative for DPD deficiency. Bone marrowaspiration revealed that therapy-related leukemia(TRL)and therapy-related myelodysplastic syndrome(T-MDS)were not the causes of the pancytopenia either. A total of 230 units of platelet transfusions and 20 units of red blood cell transfusions have been given for 32 weeks, and the patient currently requires routine blood transfusions. Fortunately, infection and bleeding never occurred. Subsequently, the patient should be monitored carefully.

Cystic Adventitial Disease of the Common Femoral Artery. Case Report and Review of the Literature.

PURPOSE: Cystic adventitial artery disease is an uncommon non-atherosclerotic peripheral vessel disease. Furthermore cystic adventitial disease of the common femoral artery is an extremely rare entity. We report the case of a 54 year-old man complaining of intermittent claudication who was referred to our vascular service. METHODS AND RESULTS: Doppler ultrasound and multidetector-row computed tomography (CT) with 3-dimensional volume rendering revealed severe stenosis with cystic an adventitial cyst in the common femoral artery. Intra-operative Doppler ultrasound showed the cyst to be multilocular type. Reversed great saphenous vein interposition was successfully placed. CONCLUSION: Removal of cyst together with artery and interposition using reversed great saphenous vein is the optimal treatment procedure to prevent recurrence.

[Examination of Resection for Pulmonary Tumors after Breast Cancer Surgery].

There are many arguments about whether surgical resection or drug therapy is better for pulmonary metastasis after breast cancer surgery. Here, we examine 9 cases of resection for pulmonary tumors suspected of being metastases from breast cancer, at our institution. The preoperative diagnosis was difficult, with nodules less than 20 mm in all cases. Of the 9 cases, 2 cases were primary lung cancer, 4 cases were metastatic pulmonary tumors, 1 case was comorbid with lung cancer and metastatic pulmonary tumors, and 2 cases were benign pulmonary tumors. The median disease-free interval (DFI) was 6.1 (1.3-8.9) years, and the median survival time was 12.5 (2.3-17.8) years after metastasectomy. There were no changes in the hormone receptors or HER2 status between primary breast tumors and metastases. Both cases of primary lung cancer were Stage ⅠA, and they were treated with radical resection. The 2 benign pulmonary tumors did not receive any unnecessary additional treatment. If a difficult-to-diagnose pulmonary tumor occurs after an operation for breast cancer, a pneumonectomy should be considered, not only for diagnosis but also for treatment.

[A Case of Resected Lymph Node Recurrence of Cancer of the Papilla of Vater].

We report the successful resection of lymph node recurrence of cancer of the papilla of Vater after pancreatoduodenectomy (PD). A 67-year-old man had undergone PD for adenocarcinoma of the papilla of Vater, and histopathological examination revealed well differentiated papillotubular adenocarcinoma, ly1, v0, T1, n (0), pStage ⅠB. One year after surgery, abdominal computed tomography revealed a mass at the left side of the residual inferior pancreaticoduodenal artery (IPDA). We resected the mass, which was diagnosed as lymph node recurrence of cancer of the papilla of Vater. The patient remains alive without any evidence of recurrence 5 years since the second operation. We suggest that complete resection of lymph node surrounding the IPDA is an important surgical procedure for cancer of the papilla of Vater. There still is only limited experience with resection for recurrence of cancer of the papilla of Vater, but our case shows that it may provide for long-term survival from recurrence of cancer of the papilla of Vater.

Hepatocyte apoptosis is enhanced after ischemia/reperfusion in the steatotic liver.

Liver steatosis is associated with organ dysfunction after hepatic resection and transplantation which may be caused by hepatic ischemia/reperfusion injury. The aim of the current study was to determine the precise mechanism leading to hepatocyte apoptosis after steatotic liver ischemia/reperfusion. Using a murine model of partial hepatic ischemia for 90 min, we examined the levels and pathway of apoptosis, and the peroxynitrite expression, serum alanine aminotransferase levels, and liver histology 1 and 4 h after reperfusion. In the steatotic liver, the peroxynitrite expression increased after ischemia/reperfusion. Significant hepatocyte apoptosis in the steatotic liver was seen after reperfusion, caused by upregulation of cleaved caspases 9 and 3, but not caspase 8. Serum alanine aminotransferase levels were elevated and histological examination revealed severe liver injury in the steatotic liver 4 h after reperfusion. In mice treated with aminoguanidine, ischemia/reperfusion-induced increases in serum alanine aminotransferase levels and apoptosis were significantly reduced in steatotic liver compared with mice treated with phosphate buffered saline. Survival of mice with steatotic livers significantly improved by treatment with aminoguanidine. Our data suggested that the steatotic liver is vulnerable to hepatic ischemia/reperfusion, leading to significant hepatocyte apoptosis by the mitochondrial permeability transition, and thereby resulting in organ dysfunction.

Hepatocyte nuclear factor-kappa beta (NF-kappaB) activation is protective but is decreased in the cholestatic liver with endotoxemia.

BACKGROUND: Obstructive jaundice (OJ) is an important clinical consideration associated with a high risk of bacteremia. Hepatocyte nuclear factor-kappa B (NF-kappaB) activation confers an antiapoptotic function. Although the occurrence of hepatocyte apoptosis has been shown in OJ, the activation and role of NF-kappaB over the time course of OJ in conjunction with endotoxemia have not yet been well defined. We hypothesized that NF-kappaB activation may be decreased over the time course of OJ and endotoxemia, which leads to severe liver injury. The aim of the current study was to examine whether NF-kappaB activation can decrease hepatocyte apoptosis and liver injury over the time course of OJ in response to lipopolysaccharide (LPS) administration. METHODS: Male C57BL/6 mice were subjected to bile duct ligation and were administered LPS intravenously at 3 days (OJ3) or 14 days (OJ14) after bile duct ligation. NF-kappaB activation; protein expressions of NF-kappaB p65, IkappaB-alpha, Ikappabeta-b, and Pin1; immunohistochemistry of poly adenosine diphosphate (ADP)-ribose polymerase p85 fragment (PARP); and serum alanine transaminase (ALT) levels were examined. RESULTS: Hepatocyte NF-kappaB activation was observed during OJ. After LPS administration, the hepatic NF-kappaB activation defined by electrophoretic mobility shift assay was decreased in the OJ14 group compared with the OJ3 group, which is consistent with a decrease in NF-kappaB p65 protein expression. Changes in phosphorylated Ikappa-B-beta but not phosphorylated IkappaB-alpha mirrored these results. Significant hepatocyte apoptosis defined by PARP immunohistochemistry was observed in the LPS-treated OJ14 relative to the LPS-treated OJ3. Hepatic expressions of tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) in the LPS OJ14 mice were upregulated relative to those in the LPS OJ3. Serum ALT levels increased significantly in the LPS OJ14 relative to other mice. The survival rate was significantly less in the LPS OJ14 relative to other mice. CONCLUSION: After prolonged OJ, exposure to endotoxemia was associated with a decrease in hepatocyte NF-kappaB activation and an increase in hepatocyte apoptosis and secondary necrosis, thus resulting in liver dysfunction.

[A curative resection with the combination of portal vein branch embolization and systemic chemotherapy in a patient with synchronous multiple and bilobar colorectal liver metastases].

A 60-year-old man was admitted to our institution having a descending colon cancer with synchronous liver metastases. Tumor marker levels were remarkably elevated and the liver metastases were multiple and located at both right lobe and segment 4. Due to lack of the remnant liver volume, left hemicolectomy and intraoperative right portal vein branch embolization were performed as a primary operation. Three weeks after the operation, he started to undergo systemic chemotherapy by mFOLFOX6. After 8 courses of the treatment, grade 3 neurotoxicity appeared, and we changed the regimen to FOLFIRI. During a total of 18 courses of the chemotherapy, the periodic CT scans revealed the liver metastases to be PR or SD, and no other metastatic lesion was detected. After the rest of chemotherapy for 7 weeks, extended right hepatectomy was performed. He had an uneventful postoperative course and the tumor marker levels immediately returned to normal levels. He has been in good health without a recurrence for 10 months after hepatectomy. The combination of portal vein embolization and systemic chemotherapy may contribute to improve respectability of synchronous multiple and bilobar colorectal liver metastases.

Does prolonged biliary obstructive jaundice sensitize the liver to endotoxemia?

Biliary obstructive jaundice (OJ) is an important clinical consideration concerning high bacteremic risk. Hepatocyte apoptosis is one of the causes of cholestatic liver injury. The aim of the current study was to examine the precise pathway and time course of hepatocyte apoptosis during OJ with LPS administration and to determine if OJ sensitizes the liver to endotoxemia. Male C57BL/6 mice were subjected to bile duct ligation and division and were administered with LPS at 3 (OJ3) or 14 (OJ14) days after surgery. Fas ligand expression, poly (adenosine diphosphate-ribose) polymerase p85 fragment immunohistochemistry, activation of caspases 3, 8, and 9, serum alanine aminotransferase levels, and hepatic adenosine triphosphate (ATP) contents were examined. Survival after LPS administration in male C57BL/6 or gld/gld (Fas ligand-deficient) mice was determined. The expression of Fas ligand increased during OJ. After LPS administration, the expression of cleaved caspases 3 and 8 increased in Sham3, Sham14, OJ3, and OJ14 mice, and it significantly increased in OJ14 compared with other mice. Poly (adenosine diphosphate-ribose) polymerase p85 immunohistochemistry showed significant hepatocyte apoptosis after LPS administration in OJ14 mice relative to OJ3. In OJ14 with LPS administration, ATP contents significantly decreased and alanine aminotransferase levels increased. Hepatocyte apoptosis was decreased in gld/gld OJ14 mice compared with C57BL/6 OJ14. All C57BL/6 OJ14 mice with LPS died, but survival in gld/gld OJ14 significantly ameliorated. In prolonged OJ with LPS administration, hepatocyte apoptosis depending on Fas ligand expression significantly increased in association with a decrease in ATP contents, thus resulting in liver necrapoptosis.

Interval period tumor progression: does delayed hepatectomy detect occult metastases in synchronous colorectal liver metastases?

BACKGROUND: Rapid remnant liver recurrence in patients with synchronous colorectal liver metastases (CRLM) is occasionally experienced after simultaneous colorectal and liver resection. We evaluated the tumor progression during interval periods to determine whether delayed hepatic resection detects occult metastases. METHODS: One hundred thirty-seven patients underwent hepatectomy for synchronous CRLM. Up to 2003, 116 patients underwent simultaneous colorectal and hepatic resection. From 2004 onward, we identified 21 patients undergoing delayed hepatectomy for synchronous CRLM. The tumor progression during interval was determined by a dynamic computed tomography scan. RESULTS: Median/mean interval between the two evaluations prior to the first and second surgery was 2/2.4 months. The median/mean number of metastases detected at each evaluation was 2/3.3 and 3/4.6, respectively. Nine of the 21 (43%) patients had new detectable metastatic lesions after reevaluation. For 11 of the 21 patients, it was necessary to reconsider planned surgical procedure which was determined prior to colorectal surgery. Hepatic disease-free survival was significantly different between patients undergoing delayed and simultaneous hepatectomy. Multivariate analysis showed that the delayed hepatectomy was a significant independent prognostic factor in hepatic disease-free survival. CONCLUSION: Tumor progression was recognized and occult metastases were detected after the interval reevaluation. Delayed hepatectomy may be a useful approach to reduce rapid remnant liver recurrence in synchronous CRLM.

Comparison of 4-Mercapto-4-methylpentan-2-one contents in hop cultivars from different growing regions.

Contributions of hop-derived thiols were examined. Extremely strong fruity, black currant-like aromas were detected in beers hopped with some U.S. cultivars. 4-Mercapto-4-methylpentan-2-one (4MMP) was supposed to be the main contributor to the fruity aroma, and the contents between cultivars were investigated. In hop pellets, a negative correlation between 4MMP concentration and copper ion content in hops was observed. 4MMP was detected only in U.S., Australian, and New Zealand cultivars, but no European ones, which are treated with copper-containing fungicides (Bordeaux mixture) and therefore have a high content of copper ions. The 4MMP content was highest in Simcoe cultivars, followed by Summit, Apollo, Topaz, Cascade pellets, and also differed between crop years. It was indicated that most 4MMP exists freely in wort or in hop pellets with only small amounts formed from precursors and that the amounts increased during the fermentation process.