Pancreatoduodenectomy with portal vein resection for distal cholangiocarcinoma.

BACKGROUND: Little is known about the value of portal vein (PV) resection in distal cholangiocarcinoma. The aim of this study was to evaluate the clinical significance of PV resection in distal cholangiocarcinoma. METHODS: Patients who underwent pancreatoduodenectomy (PD) for distal cholangiocarcinoma between 2001 and 2010 at one of 31 hospitals in Japan were reviewed retrospectively with special attention to PV resection. Short- and long-term outcomes were evaluated. RESULTS: In the study interval, 453 consecutive patients with distal cholangiocarcinoma underwent PD, of whom 31 (6·8 per cent) had combined PV resection. The duration of surgery (510 versus 427 min; P = 0·005) and incidence of blood transfusion (48 versus 30·7 per cent; P = 0·042) were greater in patients who had PV resection than in those who did not. Postoperative morbidity and mortality were no different in the two groups. Several indices of tumour progression, including high T classification, lymphatic invasion, perineural invasion, pancreatic invasion and lymph node metastasis, were more common in patients who had PV resection. Consequently, the incidence of R1/2 resection was higher in this group (32 versus 11·8 per cent; P = 0·004). Survival among the 31 patients with PV resection was worse than that for the 422 patients without PV resection (15 versus 42·4 per cent at 5 years; P < 0·001). Multivariable analyses revealed that age, blood loss, histological grade, perineural invasion, pancreatic invasion, lymph node metastasis and surgical margin were independent risk factors for overall survival. PV resection was not an independent risk factor. CONCLUSION: PV invasion in distal cholangiocarcinoma is associated with locally advanced disease and several negative prognostic factors. Survival for patients who have PV resection is poor even after curative resection.

[Chronic eosinophilic pneumonia associated with rheumatoid arthritis].

We encountered a 45-year-old woman with chronic eosinophilic pneumonia associated with rheumatoid arthritis. In May 1997, she was given a diagnosis of rheumatoid arthritis and prescribed non-steroidal anti-inflammatory drugs. After a month, she visited our hospital because of fever and cough. A chest roentgenogram and computed tomographic scan on first admission revealed peripheral infiltrative shadows in the upper fields of both lungs. Approximately 30% of peripheral blood cells were eosinophils. Furthermore eosinophils were elevated in bronchoalveolar lavage fluid and transbronchial lung biopsy specimens. A conclusive diagnosis of chronic eosinophilic pneumonia was made on these grounds. The patient responded well to steroid treatment, but was readmitted a week later because of worsening joint pain and skin eruptions in the lower extremities of both legs. A skin biopsy showed perivascular and interstitial eosinophil infiltration. The combination of steroids, a disease modifying anti-rheumatic drug, and a non-steroidal anti-inflammatory drug proved to be effective.

Endoscopic papillary dilation by balloon and isosorbide dinitrate drip infusion for removing bile duct stone.

BACKGROUND: Endoscopic papillary dilation (EPD) by balloon in the management of bile duct stones has recently been claimed to be effective for removing bile duct stones. METHODS: Without endoscopic sphincterotomy, we attempted to remove large or multiple bile duct stones through EPD combined with drip infusion of isosorbide dinitrate in 35 patients. Isosorbide dinitrate, at a rate of 5 mg/h, was administered intravenously, and a balloon dilator with a 10-mm diameter was inflated within 3 min across the papilla. Stones were then smashed using a mechanical lithotriptor, and the fragments were extracted with a basket or the balloon. RESULTS: Extraction of stones was successful in 33 (94%) of 35 patients by the combined therapy. Two of them (6%) developed mild pancreatitis. CONCLUSION: EPD combined with medical sphincter dilation was effective for large and multiple bile duct stones.

Effect of captopril on blood pressure and renin-angiotensin-aldosterone system in hypertensive patients on hemodialysis.

We have performed a long-term (6-16 months) administration of captopril in 6 hypertensive patients with renal failure undergoing hemodialysis. They were divided into two groups according to the basal renin levels (pretreatment plasma renin activity, PRA), that is, high PRA group (3 patients) and normal PRA group (3 patients). 1) In the high PRA group efficient reduction of blood pressure was obtained by small doses of captopril. In the normal PRA group, however, slight or no pressure reduction was observed. Appropriate initial dose was 10-15 mg/day and maintenance one was 75 mg/day in high PRA group. 2) Hemodialysis potentiated the hypotensive action of captopril in the high PRA group through massive removal of sodium and water. 3) In the normal PRA group PRA was regulated by serum sodium concentration and the plasma aldosterone concentration (PAC) was by serum potassium concentration, but in the high PRA group PRA and PAC were mainly regulated by captopril itself. 4) In one patient an adverse reaction consisting of strong bradycardia, dyspnea, chest pain and cold sweat was observed soon after the start of captopril medication. From these results, it was concluded that captopril was as excellent drug for the control of severe hypertension in dialysed patients having a high basal renin level.

Development of malignant hypertension in patients with uremia under hemodialysis: a case report and discussions on its etiology.

A woman, now 28 years old, was diagnosed 6 years ago as chronic glomerulonephritis by renal biopsy. From August 15, 1975 she complained of nausea, loss of appetite and weight (about 7 kg within 2 weeks). Severe hypertension (200/130 mmHg), hyponatremia (123 mEq/liter), anemia, elevated plasma renin activity (PRA), advanced azotemia, and eye ground changes of KW-II were found. Dialysis treatment was started on September 2, 1975. From November 1975 massive amounts of sodium (5,000 mEq or more monthly) and water (26 liters or more monthly) were removed by the dialysis. These intensive dialyses resulted in an elevated PRA with recurrence of severe hypertension. At the end of March 1976 she became almost blind with retinopathy of KW-IV. Potent hypotensive drugs including beta-blockers were administered, but no improvements were obtained. On March 31, 1976 nephrectomy was performed to save her life. Marked hyalinization of glomeruli and heavy thickening of intima in interlobular arteries were found in the removed kidneys. Renal artery stenosis was not recognized either macroscopically or histologically. In this patient, the amount of sodium removed by the dialysis was dependent on her diastolic blood pressure and sodium concentration of the dialysis. It may be concluded that too enthusiastic dialysis may develop malignant hypertension due to excessive renin release.

Analysis of 30 patients with malignant hypertension treated with hemodialysis.

For the past 7 years we have treated 30 patients with malignant hypertension with hemodialysis. The diagnosis of the disease was made according to the criteria recommended by the Ministry of Public Welfare, Japan, as described below. These patients were divided into three groups according to the therapies. Group A (15 patients) were medicated with large doses of beta-blockers for the control of hypertension. Characteristic features of this group were abnormally high reninemia, hyponatremia, and severe hypertension which were not controlled by large doses of beta-blockers in combination with dialysis. Their body weights were quite subnormal. Twelve patients out of 15 had essential hypertension (EH) as an underlying disease, and the remaining 3 had chronic glomerulonephritis (CN). Ten patients out of 15 died of hypertensive heart failure or hypertensive cerebrovascular accidents. Group B (6 patients) were treated by beta-blockers intermittently. They showed good results responding well to the treatment; high reninemia was brought down to normal level by the administration of beta-blockers and dialysis. Their underlying diseases were EH (3 patients) and CN (3 patients). Group C (9 patients) did not receive beta-blockers, because hypertension was easily controlled by dialysis alone. In the Group C patients, normoreninemia, normonatremia, and a favorable clinical course were characteristic. Their underlying disease was CN in all. From these results, it is concluded that the factors influencing the prognosis of te disease may be the existence of EH as an underlying disease, high reninemia, and hyponatremia which are not correctable either by administration of beta-blockers or by hemodialysis.

The effect of vitamin D2 on hypocalcemia in patients under chronic hemodialysis.

The effects of vitamin D2 (VD2) on hypocalcemia were studied in 54 hypocalcemic patients (29 males and 25 females) on chronic hemodialysis. Calcium lactate (3 g/day) or VD2 (10,000 IU/day, 50,000 IU/day and 80,000 IU/day) were administered for 4 months in order to correct the hypocalcemia. Serum calcium, phosphate and alkaline phosphatase levels were measured and the effects of VD2 on these parameters of calcium metabolism were followed. 1) Calcium lactate or 10,000 IU/day of VD2 were not effective for the correction of hypocalcemia, while 50,000-80,000 IU/day of VD2 were effective. The effects of VD2 on serum calcium concentrations were dose-dependent, and the normalization of serum calcium concentrations was achieved more rapidly with higher doses of VD2. However, in the group treated with 80,000 IU/day of VD2, many patients developed hypercalcemia, but in the group treated with 50,000 IU/day of VD2, only a few patients did it. From these results, suitable dose (initial and maintenance doses) of VD2 in dialysed patients would be 50,000 IU/day. 2) When the responder group (normal serum calcium levels after 4 months of treatment with 50,000 IU/day of VD2) and the non-responder group serum calcium levels lower than 4.2 mEq/liter on the same condition) were compared, the durations of dialysis were significantly shorter in the former than those in the latter. This fact may suggest that the effects of VD2 administration on hypocalcemia in dialysed patients are partly dependent on the residual renal function concerning the conversion of 25-OH-D3 into 1,25 (OH)2D3.

Pathological study of tracheal and pulmonary lesions in autopsy cases of congenital esophageal atresia.

One of the major causes of death in infants with congenital esophageal atresia is the lung complication. Analysis of the Annual of Pathological Autopsy Cases in Japan from 1966 to 1969 revealed that the lung complications were seen in 81% of total cases. We have carried out a detailed histological study of the trachea and lung in 4 infants who died of congenital esophageal atresia. In three of them, ciliated epithelium of the trachea was replaced by stratified squamous epithelium and the alveoli were filled with numerous foamy cells. There were only a little inflammatory change in sections studied. The constant association of these two lesions suggests cause-and-effect relationship, and we are inclined to think that retention of foamy cells in the alveoli is due to the impaired mucociliary transport mechanism in the respiratory tract.

Significance of Laurén's classification in chemotherapy of gastric carcinoma.

The effects of anticancer agents were studied on the basis of survival rates following surgery for gastric carcinomas in different histologic types of Laurén's classification. It was revealed that Laurén's classification would provide an index to the use of anticancer agents to a certain extent. Anticancer agents were effective against diffuse gastric carcinoma, and should therefore be intensively used for treatment of this malignancy. For female patients with diffuse gastric carcinoma, careful selection of adequate anticancer agents is highly necessary. Anticancer agents were less effective against intestinal-type carcinoma, and it would therefore be necessary to use anticancer agents on the aged male patients with this malignancy by taking his age and side effects of the agents into consideration.