Computed tomographic lymphography predicts the difficulty of sentinel lymph node biopsy with dye.

BACKGROUND: Sentinel lymph node biopsy (SLNB) has been a method of choice for treating breast cancer. Computed tomographic lymphography (CT-LG) provides a view of the sentinel lymph node (SLN) with the detailed lymphatic anatomy preoperatively, and the SLN is easily identified during SLNB. In this article, we examined the usefulness of CT-LG to predict the difficulty of SLNB with the dye method. METHODS: A total of 41 consecutive patients who underwent CT-LG were enrolled in this study. Each CT-LG image was reviewed by one of our co-authors. The images of lymph vessels (LVs) and SLNs were assorted into three categories: not visualized, poorly visualized, and well visualized. The time engaged in SLNB with the dye method was recorded in 30 patients. RESULTS: The time engaged in SLNB between two groups was compared: patients in whom both the SLN and LVs were well visualized (n = 16) and the remaining patients (n = 14). The former required a significantly shorter time than the latter (12.6 ± 4.1 vs. 17.6 ± 6.7 min, respectively; p = 0.025 by Mann-Whitney U test). CONCLUSIONS: Our study clearly demonstrates that the CT-LG findings of well-visualized LVs and SLNs predict the easy access to the stained LVs and SLNs. This information provides several advantages, including the fact that an easy SLNB case can be selected for a doctor with little experience in SLNB, and the volume of dye and/or length of massage can be changed for better identification of stained LVs and SLNs during SLNB.

Short-term and low-dose prednisolone administration reduces aromatase inhibitor-induced arthralgia in patients with breast cancer.

Aromatase inhibitors (AIs) are important therapeutic drugs for postmenopausal women with hormone receptor-positive breast cancer. However, adverse effects of AIs such as arthralgia have been extensively reported. We performed a joint prospective, multi-institutional investigation to find out whether a low-dose and short-term prednisolone is effective against AI-induced arthralgia in 27 patients with breast cancer. Patients were administered 5 mg of oral prednisolone once a day in the morning for only one week. Patients were then asked to answer a questionnaire about joint pain symptoms at one week, one month and two months after the beginning of prednisolone use. Joint pain symptoms improved in 67% of patients immediately after prednisolone use, with 63% still reporting analgesic effect at one month, and 52% at two months after beginning internal use of prednisolone. At one week, one month and two months after the use of prednisolone, 30%, 30% and 26% of patients reported improved daily life, respectively. Our results suggest that prednisolone could substitute non-steroidal anti-inflammatory drugs, acetoaminophen or cyclooxygenase-2 inhibitors in patients with AI-induced arthralgia.

Objective response with lapatinib in patients with meningitis carcinomatosa derived from HER2/HER1-negative breast cancer.

A 45-year-old woman with HER2(-)/HER1(-) breast cancer underwent radical mastectomy, followed by radiation and chemotherapy. However, her symptoms progressed rapidly owing to meningitis carcinomatosa and she was fitted with a urethral catheter. She also had difficulty in walking. However, immediately after treatment with lapatinib, her symptoms almost completely disappeared. The catheter was removed and she no longer needed a wheelchair. Unfortunately, after treatment was stopped, the bilateral upper limb skin metastases reappeared, the brain metastases relapsed, and she again experienced symptoms of meningitis carcinomatosa. Lapatinib was restarted, resulting in an immediate improvement in the symptoms and a reduction in the skin and brain metastases. Immunohistochemical staining of the lapatinib-sensitive metastatic skin tumor showed it to be HER2(2+), FISH(-)/HER1(-). This result suggested that the lapatinib-sensitive lesions in the brain and meninges were also HER2-positive. Carcinomatosa meningitis has a very poor prognosis and no effective treatment has yet been developed. Here, we report the first case in which lapatinib has been used to effectively treat meningitis carcinomatosa in HER2(-)/HER1(-) relapsed breast cancer.

Merits and faults of transanal ileus tube for obstructing colorectal cancer.

BACKGROUND: We report eight cases of obstructing colorectal cancer successfully managed by preoperative lavage using transanal ileus tube. METHODS: Decompression tube was transanally inserted into the colon proximal to the tumour under the guidance of the guide wire. Intestinal lavage with 1,500-2,000 mL of warm water was done every day until surgery. RESULTS: There were six men and two women; the mean age was 67 years (range, 50-82 years). Three cancers were in the sigmoid colon and five were in the rectum. Seven patients were treated with a one-stage operation with adequate lymph node dissection. In one patient, only sigmoidostomy was carried out for unresectable huge tumour. In all cases, no dilatation was observed at the proximal colon and no anastomotic failure developed. Four patients suffered from fever of unknown cause after the insertion of the tube. In one patient, the resected specimen showed ulcer by tube compression. In the other patient, the tube penetrated the intestinal wall, which was covered by mesentery. CONCLUSION: The transanal ileus tube is effective for the treatment of obstructing colorectal cancer. However, close observation is necessary because of possible perforation.

Severe localized stenosis and marked dilatation of the main pancreatic duct are indicators of pancreatic cancer instead of chronic pancreatitis on endoscopic retrograde balloon pancreatography.

BACKGROUND: Differentiation between benign and malignant localized stenoses of the main pancreatic duct is difficult by pancreatography. METHODS: A total of 48 patients with such localized stenosis who underwent endoscopic retrograde balloon pancreatography with abdominal compression were retrospectively studied. The following were examined: (1) diameter of the stenotic, prestenotic, and poststenotic ductal segments; (2) ratios of prestenotic/poststenotic, stenotic/prestenotic, and stenotic/poststenotic ductal segments; (3) length of stenosis and steepness of transition to the stenosis (proximal angle, distal angle); and (4) main duct and branch findings for peristenotic segments. RESULTS: The stenosis was diagnosed as caused by chronic pancreatitis in 27 patients and pancreatic cancer in 21 by histopathology, cytology, or clinical follow-up. The prestenotic/poststenotic ductal segments ratio and proximal angle were greater in pancreatic cancer compared with chronic pancreatitis. Severe stenosis (stenotic ductal segments less than 20% of prestenotic or poststenotic ductal segments); moderate (prestenotic ductal segments 2.5 to 3.5 times larger than poststenotic ductal segments), and severe (prestenotic ductal segments more than 3.5 times larger than poststenotic ductal segments) dilatation of the proximal duct were more frequent in pancreatic cancer than in chronic pancreatitis. Multivariate regression analyses showed that severe stenosis and dilatation were independently significant parameters that indicated a diagnosis of pancreatic cancer. Various combinations of severe stenosis, proximal dilatation, and double duct sign gave high predictive values. CONCLUSIONS: Severe stenosis, marked proximal dilatation, double duct sign, and combinations of these findings are useful indicators of malignant localized stenosis of the pancreatic duct.

Comparison of recovery of gastric phase III motility and gastric juice output after different types of gastrointestinal reconstruction following pylorus-preserving pancreatoduodenectomy.

BACKGROUND: Early gastric stasis is a frequent complication of pylorus-preserving pancreatoduodenectomy (PPPD). However, few reports have addressed this phenomenon in relation to the type of gastrointestinal reconstruction. We compared gastrointestinal motility and gastric juice output after two different types of gastrointestinal reconstruction following PPPD, end-to-side duodenojejunostomy after pancreaticojejunostomy and hepaticojejunostomy (group 1) and end-to-end duodenojejunostomy before pancreaticojejunostomy and hepaticojejunostomy (group 2). METHOD: In a total of 25 patients, 10 in group 1 and 15 in group 2, who underwent PPPD, manometry was repeated to assess gastric and jejunal motility until the first occurrence of phase III activity of gastric cyclic motor activity (CMA). The plasma level of motilin was measured in each phase of the gastric CMA and compared between the two groups. The daily volume of gastric juice output through a gastrostomy tube was also recorded for comparison. RESULT: There was no significant difference in the time period for recovery of gastric phase III activity and gastric juice output between the two groups. However, abnormal contractions with an increased basal pressure appeared frequently in the afferent jejunal loop only in group 1. The plasma motilin level after PPPD showed no apparent cyclic change even after the recovery of gastric phase III in either group. CONCLUSION: Gastrointestinal reconstructive procedures have almost no effect on the recovery of gastric CMA. The plasma motilin concentration does not play a major role in the recovery of gastric CMA in the early postoperative period after PPPD.

Laparoscopic choledochotomy for bile duct stones.

In the era of laparoscopic surgery, treatment strategies for common bile duct stones remain controversial. Laparoscopic choledochotomy is usually indicated only when transcystic duct exploration is not feasible. However, laparoscopic choledochotomy provides complete access to the ductal system and has a higher clearance rate than the transcystic approach. In addition, primary closure of the choledochotomy with a running suture and absorbable clips facilitates the procedure. Therefore, to avoid postoperative biliary stenosis, all patients with bile duct stones can be indicated for choledochotomy, except for those with nondilated common bile duct. Placement of a C-tube also provides access for the clearance of possible retained stones by endoscopic sphincterotomy as a backup procedure. C-tube placement, in contrast to T-tube insertion, is advantageous in terms of a relatively short hospital stay. In conclusion, laparoscopic choledochotomy with C-tube drainage is recommended as the treatment of choice for patients with common bile duct stones.

Effect of truncal vagotomy on sphincter of oddi cyclic motility in conscious dogs.

OBJECTIVE: To evaluate the effects of truncal vagotomy at the diaphragmatic level on the sphincter of Oddi (SO) motility. SUMMARY BACKGROUND DATA: Cholelithiasis is a well-known late complication after gastrectomy and/or vagotomy. The mechanism of gallstone formation is only partly understood, and few studies address the effects of vagotomy on SO cyclic motility in conscious subjects. METHODS: In conscious dogs, SO motility was recorded by retrograde infusion manometry through a duodenal cannula before and after bilateral truncal vagotomy at the diaphragmatic level. Effects of cholecystokinin-octapeptide and feeding were also evaluated before and after vagotomy. RESULTS: SO cyclic motility and the gastroduodenal migrating motor complex continued to occur during postvagotomy fasting. Intermittent inhibitions of the SO and duodenal contractions disappeared during phase 3 of the migrating motor complex. SO basal pressure significantly decreased, whereas the amplitude significantly increased. Cholecystokinin-octapeptide inhibited SO contractions before and after vagotomy. The amplitude of SO contractions increased and their frequency decreased after feeding; however, these effects disappeared after vagotomy. CONCLUSIONS: SO cyclic motility and the effects of feeding change after truncal vagotomy at the diaphragmatic level. These facts may at least partly explain gallstone formation after gastric surgery and/or vagotomy.

Gastric phase 3 motility after pylorus-preserving pancreatoduodenectomy.

OBJECTIVE: To analyze factors affecting the recovery course of phase 3 activity of the gastric migrating motor complex after pylorus-preserving pancreatoduodenectomy (PPPD) and investigate effects of the recovery of gastric phase 3 on gastric emptying after feeding. SUMMARY BACKGROUND DATA: Whether early recovery of gastric phase 3 during fasting would predict early recovery of the fed-state gastric emptying function after PPPD has not been well documented. METHODS: Manometric recording from the gastric antrum was repeated at a weekly interval until the first appearance of gastric phase 3 in 57 patients after PPPD. Twenty-three clinical parameters were assessed as possible factors affecting the recovery course of gastric phase 3 by simple and multiple regression analyses. A gastric emptying study after feeding of a test meal was performed by the acetaminophen method and the values were compared between patients with and without gastric phase 3 after PPPD. RESULTS: The mean period before the first appearance of gastric phase 3 was 38 days. Among 23 parameters, only lymph node dissection along the hepatoduodenal ligament significantly delayed recovery of gastric phase 3 after PPPD by univariate and multivariate analyses. The presence or absence of gastric phase 3 in the early postoperative period did not influence gastric emptying after feeding in the intermediate period after PPPD. CONCLUSIONS: Avoiding lymph node dissection along the hepatoduodenal ligament, if applicable, may contribute to early recovery of gastric phase 3 after PPPD. The recovery state of gastric phase 3 during fasting, however, is not necessarily consistent with the degree of improvement of gastric emptying after feeding.

Biliary sphincter motility after neural isolation of the pancreatoduodenal region in conscious dogs.

BACKGROUND: Several neural and hormonal factors are known to affect the motility of the sphincter of Oddi. However, the precise mechanisms of the control of sphincter motility have not been completely explored. We investigated the relationship of canine biliary sphincter motility when it is extrinsically denervated by neural isolation of the pancreatoduodenal region. METHODS: Interdigestive and postprandial sphincter motility in a denervated pancreatoduodenal segment and effects of cholecystokinin-octapeptide were studied in 7 conscious dogs. Data were compared with those of 7 neurally intact control dogs. RESULTS: After extrinsic denervation of the pancreatoduodenal region, sphincter motility exerted a cyclic change in concert with the duodenal myoelectric cycles; this change involved short cyclic bursts of motor activity, which gradually increased in intensity. The increase in the cyclic bursts of motor activity was also cyclic and associated with an increase in the plasma motilin concentration. Neural isolation of the pancreatoduodenal region increased sphincter basal pressure and motility index (integral per minute). In the denervated biliary sphincter, the feeding pattern and temporary inhibitory effect of feeding, as seen in controls, were absent, which suggests the role of extrinsic nerves in delivering bile into the duodenum after feeding. In the denervated dogs, cholecystokinin-octapeptide caused excitation of the sphincter activity, instead of relaxation observed in controls. CONCLUSIONS: Extrinsic innervation to the pancreatoduodenal region has an inhibitory effect on biliary sphincter motility. Abnormalities in extrinsic innervation to the biliary sphincter might increase the resistance of the sphincter to the bile flow and induce bile stagnation.