[Steroid resistance of severe asthma - mechanisms and therapeutic targets].

Asthma therapy in general has improved a lot in recent years, but it is still a major problem that severe asthma, which accounts for 10 to 20%, still suffers from strong symptoms on a daily basis despite all therapeutic agents used in combination. American SARP and European ENFUMOSA started in 2000 to advance pathophysiological insights of severe asthma. Clinical usage of antibodies and inhibitors against IgE, TNF, IL-5, IL-4, IL-13, and TSLP are also accumulating. Some of these molecular-targeted drugs improve respiratory function and reduce acute exacerbations in patients with severe asthma. Until now, cytokines have been assumed to be involved in chronic inflammation, but it is also interesting to elucidate the pathways of how cytokines are involved in respiratory function and acute exacerbations. We registered approximately 100 steroid-dependent asthma patients in Japan. Although long-lasting poor control of the disease was considered the cause of severe asthma in the past, steroid dependence in one third of the cases occurred within 2-3 years after the onset. Steroid resistance seems a key process from the early stage of the disease. Steroid resistance of T cell level was induced by extracellular co-stimulation and cytokine signals. The inhibition may improve steroid sensitivity and treat steroid-resistant asthma. Therefore, we established a steroid-resistant asthma model for the first time by transferring steroid resistant T cell clones, and analyzed the steroid sensitivity recovery effect of CTLA4-Ig. In addition, a multicenter, double-blind, placebo-controlled exploratory trial was performed as a POC study investigating the efficacy of abatacept in treatment-resistant severe asthma. Elucidation of the pathophysiology and mechanism by which steroids do not work is expected to be a breakthrough for the prevention and treatment of severe asthma.

[Pancreatic Head Cancer Invading the Ascending Part of the Duodenum with Difficulty in Diagnosis-A Case Report].

A 61-year-old man visited our hospital because of nausea and vomiting. Abdominal CT revealed a severe stenosis of the ascending part of the duodenum but no evidence of tumors in the duodenum or pancreas. Upper gastrointestinal endoscopy showed severe stenosis of the ascending part of the duodenum with an ulcerative lesion. A biopsy of the site showed no evidence of malignancy. Nevertheless, duodenal and/or pancreatic cancer(s)could have caused the stenosis; therefore, we decided to perform an operation for the diagnosis and treatment of the obstruction. The surgery revealed severe stenosis of the ascending part of the duodenum with scar tissue. We performed subtotal stomach-preserving pancreaticoduodenectomy. Pathological findings showed pancreatic head cancer invading the ascending part of the duodenum. In this case, the diagnosis was difficult to make preoperatively because of the lack of an obvious neoplastic lesion. We believe duodenal invasion by pancreatic cancer without recognizing any tumor mass on CT is rare.

Accompanying role of hepato-biliary-pancreas surgeon in urological surgery.

INTRODUCTION: The present case reports demonstrated the accompanying surgical support from hepato-biliary-pancreas (HBP) surgeons for urological surgery to secure operative safety because HBP surgeons are well experienced in dissecting techniques for mobilization of the liver or pancreas. We experienced 9 consecutive patients who underwent nephrectomy, adrenectomy or resection of retroperitoneal tumors by urological surgeons. Cardiovascular intervention was also required in cases of long tumor thrombus into the vena cava. CASES: All patients had no severe co-existing diseases except the main tumor. Reverse T-shape incision was performed in 7 cases and thoracolaparotomy in two. Dissection and mobilization at the site of severe compression by the urinary tumors were performed in three cases. Partial liver resection was performed for testicular liver metastases in two, and right hepatectomy for right renal cancer was performed in one. Encircling the vena cava and preparation of transection for tumor thrombi were performed in three, and among these, cardiovascular intervention was necessary in two because of extension into the right atrium. During admission, all patient outcomes were uneventful without severe complications. We herein showed the representative two cases of combined surgery. DISCUSSION: and conclusion The point of this case report is the coordination between each surgeon and anesthesiologist under precise perioperative planning or management. The role of HBP surgeons is to provide information as a specialist on the operative field for urological or cardiovascular surgery to achieve operative safety.

Horizontal traumatic laceration of the pancreas head: A rare case report.

INTRODUCTION: This case report is intended to inform acute care surgeons about treating rare horizontal laceration of the pancreas head caused by blunt trauma. CASE PRESENTATION: A 57-year-old woman who sustained blunt abdominal trauma during a car crash was transported to the emergency center of our hospital with unstable vital signs due to hemorrhagic shock. Computed tomography showed transection of the pancreas head and massive intra-abdominal hemorrhage. She was referred for emergency surgery because of a transient response. Laparotomy at five hours after the accident initially revealed consistent massive bleeding from branches of the superior mesenteric artery and vein, which we resolved by suturing the vessels without damaging the main trunks. A horizontal laceration and complete transection of the pancreatic head were then confirmed but the main pancreatic duct remained intact. The lower part of the pancreatic head including the uncus with the attached part of the duodenum was resected, and the pancreatic stump remaining after transection was fixed by suturing. The jejunal limb was attached to the remnant duodenum by side-to-side functional anastomosis. Although gastric emptying was delayed for one month after surgery, the postoperative course was good and the patient recovered at three months thereafter. The embryonic border of pancreas head accompanied with pancreatic divisum was considered for this laceration without disruption of the main pancreatic duct. DISCUSSION: Blunt pancreatic trauma usually causes vertical transection and thus, horizontal transection is considered rare. The embryological anatomical border between the ventral and dorsal pancreas due to pancreatic divisum was supposed to be transected and therefore the main pancreatic duct was not damaged. CONCLUSION: Hemorrhagic shock and rare pancreatic head trauma were treated by appropriate intraoperative management.

Treatment of intestinal perforation in extremely low-birthweight infants.

BACKGROUND: The mortality of intestinal perforation in extremely low-birthweight infants (ELBWI) is high. It still remains to be determined whether peritoneal drainage is a definitive treatment instead of laparotomy. The authors used bedside peritoneal drainage (BSPD) as the diagnostic procedure, and exchange transfusion (ET) as the preparatory procedure for invasive stress of laparotomy. The treatment protocol is composed primarily of laparotomy combined with BSPD and ET. METHODS: ELBWI who developed intestinal perforation during hospitalization between 1993 and 2000 were treated according to the aforementioned protocol. Their medical records were examined retrospectively. RESULTS: Eight ELBWI were identified. The subjects' birthweights ranged from 553 to 892 g and the gestational age ranged from 23 to 26 weeks. The subjects consisted of five cases with idiopathic intestinal perforation, two cases with necrotizing enterocolitis, and one case with meconium plug syndrome. Laparotomy was performed in all cases, and BSPD was performed in seven cases. Intestinal perforation was definitively diagnosed by X-ray only in three cases, while by stool-like drainage in BSPD in the other five cases. Seven (87.5%) cases survived. CONCLUSION: In this limited experience, the treatment mainly composed of laparotomy combined with BSPD and ET appeared beneficial.