Recurrent bleeding from a duodenal diverticulum 8 years after endoscopic treatment: case report and review of the literature.

A 70-year-old woman presented with a 2-day history of tarry stool. She had a history of hemorrhage from a duodenal diverticulum of the 2nd portion 8 years previously that had been managed successfully by endoscopic hemostasis. Initial gastrointestinal endoscopy revealed ulceration of the diverticulum with no active bleeding; nevertheless the ulceration was presumed to be the source of the tarry stool. Despite medical treatment, bleeding started again, but endoscopic ethanol injection achieved hemostasis. When bleeding started yet again 8 days after the endoscopic therapy, the patient underwent diverticulectomy. Although duodenal diverticula are frequently found in the adult gastrointestinal tract, they rarely show hemorrhage. Recently, there has been controversy about whether bleeding diverticula should be managed surgically or endoscopically. We describe for the first time a rare case of recurrent hemorrhage of a duodenal diverticulum after an 8-year interval; the case was treated by surgical diverticulectomy as a definitive therapy for the recurrent bleeding ulcer. We also present a review of the literature.

Resection of liver metastasis from gastric adenocarcinoma.

BACKGROUND/AIMS: To determine the factors influencing the prognosis of patients undergoing resection of liver metastases from gastric adenocarcinoma. METHODOLOGY: Over a 10-year period, at Kiryu Kousei General Hospital, 12 patients underwent potentially curative hepatectomy for metastatic adenocarcinoma of gastric origin. Two patients were excluded from this study, one because of postoperative death and one due to insufficient follow-up. We retrospectively examined the following factors: including TNM classification of the primary tumor, disease-free interval between gastric and hepatic resection, number and maximum diameter of the metastases, histological differentiation of the metastases, and the presence of lymphocyte aggregation enclosing the metastatic lesions. Survival rates were estimated by the Kaplan-Meier method and the weighting of each factor was compared by the log-rank test. RESULTS: The overall 5-year survival rate of the 10 patients was 10%. The median survival time after hepatectomy was 16.3 months, ranging from 3.1 to 245.7 months. Eight patients died of recurrent cancer and 1 died of unrelated septic shock with no evidence of cancer recurrence. Only one patient was alive without recurrence at the time of maximum follow-up. A significant survival advantage was noted in patients with disease-free interval > or = 1 year, and those with metastatic tumors < 5 cm in maximum diameter and/or enclosed by the aggregated lymphocytes, when compared with patients with disease-free interval < 1 year and those with metastatic tumors > or = 5 cm and/or directly infiltrated hepatic parenchyma. CONCLUSIONS: It was suggested that hepatectomy should be attempted in patients where the disease-free interval was > or = 1 year and with metastatic nodules < 5 cm. Lymphocyte aggregation around the metastatic tumor is a good prognostic sign for long-term survival.

Resection of liver metastasis after a pancreatoduodenectomy for pancreatic cancer: a case report.

A case of resected liver metastasis from pancreatic cancer, in a 69-year-old woman who obtained a relatively long survival, is presented. Primary pancreatic cancer was found in a patient presenting with obstructive jaundice and a loss of appetite. A pylorus-preserving pancreatoduodenectomy was carried out on December 2, 1996. Eleven months later, a 1.5-cm mass was found in the right posterior segment of the liver. Although the tumor size had increased to 2.5 cm 5 months later, no other metastases were observed. Therefore, the right posterior segment of the liver was resected. Eleven months after the second operation, recurrence was found in the cut surface of the liver and the left caudate lobe. She died on May 1, 1999. This case demonstrated a relatively favorable prognosis in comparison to other common type of liver metastasis from pancreatic cancer. This study discusses the peculiarities of this case and emphasizes the necessity to carefully select the patients before attempting to resect the liver metastasis from pancreatic cancer.

Factors influencing survival in 33 patients undergoing resection of hepatic metastases from colorectal cancer.

BACKGROUND/AIMS: To determine the factors influencing the prognosis of patients undergoing resection of hepatic metastases from colorectal cancer. METHODOLOGY: Between December 1981 and March 1998, 33 patients underwent potentially curative hepatic resection for metastatic colorectal cancer at the Kiryu Kousei General Hospital. We retrospectively examined 15 factors, including 3 clinical factors, 5 primary tumor characteristics and 7 metastatic tumor characteristics. Survival rates were estimated by the Kaplan-Meier method, and the weighting of each factor was compared by the log-rank test. We used univariate and multivariate analyses to assess any associations between the factors and mortality. RESULTS: The 30-day operative mortality was 0%. The 5-yr survival rate of the 33 patients was 43%. A significant survival advantage was noted in patients with 1 or 2 metastatic lesions (25/33, 76%), patients who underwent systematic anatomical resection (14/33, 42%) and male patients (16/33, 48%), compared with patients with 3 or more lesions (50% and 17%, P = 0.021), patients who underwent non-systematic resection (67% and 23%, P = 0.005) and female patients (65% and 20%, P = 0.011), respectively. No statistical influence on survival was found in the multivariate analysis of these 3 factors. Recurrence was identified in 24 patients (73%) and 19 of them died of recurrent cancer. CONCLUSIONS: Surgical resection of hepatic metastases from colorectal cancer is safe and potentially curative in appropriately selected patients.

Effects of prostaglandin E1 on hepatic blood flow in conscious dogs with chronic biliary obstruction.

To evaluate the effects of prostaglandin E1 (PGE1) on the hepatic circulation in cholestasis, hepatic arterial blood flow (HAP), portal venous blood flow (PVF), cardiac output, and heart rate during PGE1 infusions were investigated before and 2 weeks after biliary obstruction in conscious dogs by a transit-time ultrasonic flowmeter. In the control period, HAF and PVF increased dose dependently with the infusion of PGE1 from 0.05 to 0.5 micrograms/kg/min. During the biliary obstruction period, a lower dose of PGE1 increased HAF and PVF. The plasma concentration level of PGE1 during the infusion of PGE1 was significantly higher at each dose in the cholestatic animals. These results suggest that the metabolism of PGE1 is attenuated by cholestasis. Plasma PGE1 concentrations should be useful in deciding the optimal dose of PGE1.

Clinicopathologic study on pancreatic cancer associated with pancreatic stones.

Four cases of pancreatic cancer associated with pancreatic stones were investigated clinicopathologically. In Case 1, pancreatic cancer was diagnosed 2 yr 9 mo after the diagnosis of pancreatolithiasis. Numerous large stones were present throughout the pancreas, and stones in the resected specimen were embedded in the tumor. Chronic inflammation, including inflammatory infiltration and fibrosis, were found around the pancreatic duct where the stones were present, both within and adjacent to the tumor, suggesting that chronic pancreatitis had been present for a protracted period. In Cases 2-4, a few small free stones were found in the dilated pancreatic ducts and a cyst upstream from the tumor, but there were no stones noted within the tumor. Microscopically, mild atrophy of the pancreatic parenchyma and fibrosis were seen. In each of these three cases, it was considered that the pancreatic cancer was the primary event, with the pancreatic stones arising as a secondary process. The pancreatic cancers associated with pancreatic stones were classified into two groups, one with pancreatic stones preceding the pancreatic cancer and the other three cases in which the reverse occurred.

Hepatic blood flow after acute biliary obstruction and drainage in conscious dogs.

BACKGROUND AIMS: Obstructive jaundice is a factor which effects hepatic blood flow and the relative contribution of the hepatic arterial flow and portal venous flow. In this study, and were measured in conscious dogs and the influence of biliary obstruction and drainage was investigated. MATERIAL AND METHODS: Hepatic arterial flow (HAF) and portal venous flow (PVF) after biliary obstruction and subsequent drainage were continuously measured in conscious dogs using implantable transit time ultrasonic flow-meters. RESULTS: After biliary obstruction hepatic arterial flow rapidly increased compared to the pre-obstructed values(p < 0.01), while portal venous flow was significantly decreased (p < 0.01). Total hepatic blood flow was initially increased (p < 0.01) until 2 hours after obstruction. It then decreased gradually. After 2 weeks, it was less than the pre-obstructed values, but this was not significant. Biliary drainage was performed after 2 weeks. Hepatic arterial flow subsequently decreased (p < 0.01) and portal venous flow increased (p < 0.05). Blood flow did not change. CONCLUSION: Biliary obstruction resulted in significant changes in liver circulation. Biliary drainage facilitated recovery from these changes.

The effects of intravenously infused catecholamines on hepatic blood flow in conscious dogs with experimental obstructive jaundice.

This study was conducted to examine how the effects of dopamine and dobutamine on hepatic blood flow were influenced by obstructive jaundice in a conscious canine model. Prior to biliary obstruction, portal venous blood flow (PVF) increased in response to the infusion of either dopamine or dobutamine: dopamine infused at 8 micrograms/kg per min produced an increase of 19 +/- 0% in PVF, while dobutamine infused at 16 micrograms/kg per min produced an increase of 30 +/- 2%. Although hepatic arterial blood flow (HAF) decreased dose-dependently in response to the infusion of dopamine, no significant change was observed in HAF in response to any dose of dobutamine. Obstructive jaundice attenuated or completely abolished the PVF-increasing effect of dopamine, whereas it did not significantly alter the effect of dobutamine on hepatic blood flow. In dogs with obstructive jaundice, dopamine at 16 micrograms/kg per min produced a decrease of 17 +/- 3% in PVF. These findings suggest that dobutamine is more effective than dopamine for increasing hepatic blood flow in patients with obstructive jaundice.

[A clinical study of 76 cases in carcinoma of the colon and rectum with metastasis to the peri-aortic lymph nodes. With particular reference to the skip metastasis in carcinoma of the sigmoid colon to the peri-aortic lymph nodes].

The therapeutic result by tumorous site were evaluated in 76 cases of carcinoma of the colon and rectum with the confirmed presence of metastasis to the peri-aortic lymph nodes. The results revealed that significant good out-comes were noted in the relatively non-curative cases of carcinoma of the sigmoid colon, with particularly good prognosis being found in six cases with skip metastasis. There was a 26.1% (6/23) incidence of the skip metastasis in carcinoma of the sigmoid colon with the peri-aortic lymph nodes metastasis. We confirmed two lymphatic routes of the skip metastasis; one route was from the lymph nodes near the tumor to the para-aortic lymph nodes directly, and the other was from the lymph nodes near the tumor to the lymph nodes at the aortic diffract directly and finally to the para-aortic lymph nodes. In the all six cases, the peri-aortic lymph nodes metastasis occurred only in inferior site of the inferior mesenteric artery. The average number of the peri-aortic lymph nodes metastasis were as few as 1.7 in these cases. The prognosis was favorable with three of the six cases scoring a three-year survival and included a five-year survival case.