Quadruple (1440 degrees) intestinal volvulus.

Key Clinical Message: A whirl sign on contrast-enhanced abdominal CT scan is indicative of intestine twisted around the mesenteric vessels, and is observed in cases of strangulated obstruction, signaling compromised intestinal circulation. In cases of intestinal volvulus, surgery is necessary to untwist the affected bowel, and resection is necessary if necrosis is present. Abstract: A 31-year-old Japanese man presented with acute lower abdominal pain and vomiting. Contrast-enhanced abdominal computed tomography (CT) revealed a 1440-degree clockwise torsion of superior mesenteric artery and a whirl sign. Intestinal volvulus in adulthood with a background of malrotation is extremely rare. Contrast-enhanced CT is effective for diagnosis.

Therapeutic Outcome of Multidisciplinary Treatment in Unresectable Biliary Tract Cancer: A Multicenter Retrospective Analysis.

Background: There is little established evidence regarding treatment strategies for unresectable biliary tract cancer (BTC). This study aimed to clarify the situation of multidisciplinary treatment for unresectable BTC in the 2000s when there was no international standard first-line therapy. Methods: We retrospectively reviewed 315 consecutive patients with unresectable BTC who had been treated at seven tertiary institutions in Kanagawa Prefecture, Japan between 1999 and 2008. Results: The unresectable factors were as follows: locally advanced, 101 cases (32.1%); hematogenous metastases, 80 cases (25.4%); and peritoneal dissemination, 30 cases (9.5%). Chemotherapy or radiation therapy was administered to 218 patients (69.2%). The best supportive care was provided in 97 cases (30.8%). The most common regimen was gemcitabine monotherapy, followed by gemcitabine combination therapy and S-1 monotherapy. The 1- and 2-year survival rates of all patients were 34.6% and 12.2%, respectively. The median survival time (MST) was 8 months in all patients. The 1-year survival rate was 65%, and the MST was 12 months among the locally advanced patients, whereas patients with peritoneal dissemination had the worst outcome; the 1-year survival rate was 7%, and the MST was 5 months. Among treated 90 cases of perihilar cholangiocarcinoma, patients who received chemoradiotherapy (n = 24) had a significantly better outcome than those who received chemotherapy alone (MST: 20 vs. 11 months, P < 0.001). Conclusions: Unresectable BTC has heterogeneous treatment outcomes depending on the mode of tumor extension and location. Multidisciplinary treatment seems useful for patients with locally advanced BTC, whereas patients with metastatic disease still have a poor prognosis.

A rare case of Epstein-Barr virus-positive mucocutaneous ulcer that developed into an intestinal obstruction: a case report.

BACKGROUND: Epstein-Barr virus-positive mucocutaneous ulcer (EBV-MCU) is a new category of mature B-cell neoplasms. Ulcers occur in the oropharyngeal mucosa, skin, and gastrointestinal tract. The onset of EBV-MCU is suggested to be related to the decreased immunity of the patient, the causes of which include the use of immunosuppressive agents and aging. EBV-MCU may regress spontaneously and it often has a benign course after the dose reduction or discontinuation of immunosuppressive agents or during follow-up. Here, we report the case of a patient who required surgical resection for the intestinal obstruction arising from EBV-MCU. CASE PRESENTATION: A Japanese elderly male visited our hospital with chief complaints of a palpable mass and dull pain in the left upper quadrant, loss of appetite, and weight loss. Although abdominal computed tomography and total colonoscopy (TCS) revealed a tumor with circumferential ulcer in the transverse colon, histopathological analysis of a biopsy specimen of this lesion showed only nonspecific inflammation. Because the tumor spontaneously regressed during the time he underwent tests to obtain a second opinion from another hospital, TCS was reperformed on the patient. TCS revealed that the tumor decreased in size and the inflammatory changes in the surrounding mucosa tended to improve; however, tightening of the surrounding mucosa due to scarring was observed. Another histopathological analysis of a biopsy specimen showed widespread erosion of the mucosa and the formation of granulation tissue with marked infiltration of various inflammatory cells into the mucosal tissue of the large intestine. Moreover, some of the B-lymphocyte antigen CD20-positive B cells were also positive for EBV-encoded small RNA-1, suggesting the possibility of EBV-MCU. Later, the tumor developed into an intestinal obstruction; thus, the transverse colon was resected. Histopathological analysis of the resected specimen demonstrated scattered Hodgkin and Reed-Sternberg-like multinucleated large B cells in addition to EBER-1-positive cells. The patient was finally diagnosed as having EBV-MCU. CONCLUSIONS: This is the first report of a case of EBV-MCU that developed into an intestinal obstruction requiring surgical resection. It is necessary to consider the possibility of EBV-MCU when examining an ulcerative or tumorous lesion in the gastrointestinal tract.

[Quality Control of Medical Instruments and Cleaning Water].

PURPOSE: Herein we aimed to investigate the degradation of surgical instruments in our hospital and how water quality affects the rate of metal corrosion. MATERIALS AND METHODS: We observed 279 stainless steel instruments, and determined the presence of damage like metal corrosion or scale formation. We also measured the concentrations of chloride(Cl-)and silicate(SiO44-)ions in the water used for cleaning in our operating rooms, including tap water from the city water supply and reverse-osmosis(RO)filtered water. RESULT: Pitting corrosion was observed on 71% of the instruments we investigated. The concentration of Cl- was 0.7mg/L in tap water and 0.1mg/L in RO water, while the concentration of SiO44- was 0.3mg/L in both the tap and RO water. DISCUSSION: Of the dissolved ions Cl- and SiO44-, Cl- is more of a concern, as it causes pitting corrosion over time, while SiO44- causes scale formation. Considering the typical water quality in the operating-room environment, degradation must be monitored for the general maintenance of metal surgical instruments.

Two Cases of Micro-Arteriovenous Fistula in the Lower Extremity with Misdiagnosis of Refractory Cellulitis.

We report our experience of two cases of refractory cellulitis caused by peripheral micro-arteriovenous fistulas (AVFs) in the lower extremity. The micro-AVFs were so small that they could not be located accurately; further, the patients' symptoms differed markedly from those previously reported for AVF. AVF is known to cause ischemic symptoms. In contrast, micro-AVF causes congestive symptoms and remains undetected in the majority of patients. Identification of this pathology is crucial to enable effective treatment by the ligation of the incompetent perforator vein that increases venous hypertension, leading to congestive symptoms.

[A case of mediastinal pancreatic pseudocyst accompanied by pancreatic pleural effusion].

A 62-year-old man was admitted with dyspnea. Computed tomography (CT) revealed left massive pleural effusion and a cystic lesion in the posterior mediastinal compartment extending to the pancreatic head via the esophageal hiatus. The pleural effusion had a high amylase content. Based on these findings, we diagnosed mediastinal pancreatic pseudocyst accompanied by pancreatic pleural effusion. We treated him with CT-guided puncture and endoscopic pancreatic drainage. Endoscopic pancreatic treatment is possible for pancreatic pseudocysts.

The Rho kinase inhibitor fasudil is involved in p53-mediated apoptosis in human hepatocellular carcinoma cells.

PURPOSE: Rho kinase is an important factor in tumor progression. We demonstrated that Rho kinase-associated coil-containing protein kinase (ROCK) is expressed in hepatic tissues in hepatocellular carcinoma (HCC) and confirmed its roles in cell survival in HCC cells using the ROCK inhibitor, fasudil. METHODS: ROCK protein levels were estimated in hepatic tissues with HCC compared with healthy liver tissues or hepatic hemangioma tissues using immunohistochemistry. Furthermore, HepG2 and Huh7 cells were cultured with ROCK inhibitor, fasudil for 24 h in vitro. Cell proliferation was evaluated using the 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium, inner salt assay, and apoptotic cells were detected by cell death ELISA. The expression apoptosis-related proteins were analyzed using Western blotting. RESULTS: Fasudil significantly decreased cell proliferation and induced apoptosis mediated by increases in p53, Bax, caspase-9, and caspase-3 in HepG2 and Huh7 cells. The induction of apoptosis was inhibited in HCC cells precultured with p53 decoy oligodeoxynucleotide. CONCLUSION: These results suggest that ROCK inhibits the p53-mediated apoptosis pathway in HCC. Fasudil may thus be a beneficial approach to HCC therapy.

Mixed acinar-endocrine carcinoma of the pancreas with intraductal growth into the main pancreatic duct: Report of a case.

The patient was a 75-year-old asymptomatic man, in whom a tumor mass in the pancreatic tail had been found 6 months earlier. Computed tomography revealed a mass 7 cm in diameter, and an enhancement with contrast medium was observed at the periphery and partially inside the mass, but not in most parts of the tumor. Endoscopic retrograde cholangiopancreatography showed a filling defect in the main pancreatic duct. A distal pancreatectomy was performed because of the possibility of a malignant tumor. The tumor consisted of a lobular invasive growth component and a component with intraductal growth into the main pancreatic duct, and histologically the tumor cells had solid acinar to partially trabecular/tubular patterns. Trypsin (an acinic cell marker) expression was widely observed, followed by the expression of chromogranin A (an endocrine cell marker) in about 30% of the tumor cells. The tumor was diagnosed as mixed acinar-endocrine carcinoma according to the WHO classification.

Second surgery after a pancreaticoduodenectomy in patients with periampullary malignancies.

BACKGROUND/AIMS: Few case reports have previously documented a second surgery after pancreaticoduodenectomy due to recurrence or other reasons in patients with periampullary malignancies. The present report summarized the experience of this clinic with secondary surgery after Pancreaticoduodenectomy (PD). METHODOLOGY: During the past 7 years, 7 out of 95 patients with periampullary malignancies underwent a second surgery after pancreaticoduodenectomy at this institution. The clinical courses of these patients are presented and 2 interesting cases are shown in the present study. RESULTS: One patient with lower bile duct adenocarcinoma underwent a remnant splenopancreatectomy due to pancreatic recurrence 36 months after pancreaticoduodenectomy. The other patient with lower bile duct adenocarcinoma underwent a hepatectomy due to a solitary liver metastasis 47 months after a pancreaticoduodenectomy. These 2 patients have survived 4 and 13 months after the second surgery. In the 7 patients requiring secondary surgery, 5 underwent the procedure due to recurrent disease, and 4 of the 5 received the second surgery to remove the lesion. The mean interval between pancreaticoduodenectomy and the second operation was 32 months in the 5 patients with recurrent disease and 27 months in the all 7 patients. One of the 5 patients died of recurrent disease only 5 months after the second procedure because the surgery was a palliative bypass. However, the other 3 survived more than 1 year after the resection of the lesion at the recurrent site. CONCLUSIONS: The present study reports 2 rare cases with lower bile duct adenocarcinoma in which a recurrent tumor was removed after pancreaticoduodenectomy. In this study, 4 patients undergoing a curative re-operation survived more than 1 year after the surgery. The present study was small, but the findings are significant because of the scarcity of reports of patients undergoing secondary surgery after PD.

Prophylactic irrigation around a pancreaticojejunostomy for the treatment of a pancreatic fistula after a pancreaticoduodenectomy in patients with a risky pancreatic remnant.

BACKGROUND/AIMS: Postoperative morbidity after a pancreaticoduodenectomy remains high mainly due to pancreatic fistula, but effective methods to prevent the development of pancreatic fistula have yet to be established. The present study prospectively investigated whether postoperative prophylactic irrigation around the pancreaticojejunostomy might be able to prevent eventual pancreatic fistula and infectious complications after a pancreaticoduodenectomy. METHOD: Among 75 patients undergoing a pancreaticoduodenectomy between 2003 and 2005, 50 patients in whom the drain amylase level on postoperative day 1 were 1,500 IU/L or more were selected for the present study. Twenty-six of the 50 patients underwent postoperative prophylactic 72-hour continuous irrigation around the pancreaticojejunostomy starting from postoperative day 1 (Irrigation group). On the other hand, 24 of them did not undergo such irrigation (Non-irrigation group). The incidence of pancreatic fistula, infectious complications, delayed gastric emptying, and the length of hospital stay were then compared between the 2 groups. RESULTS: The incidences of pancreatic fistula, wound infection, drain infection, sepsis, delayed gastric emptying, overall morbidity, and length of hospital stay were found to be significantly less in the irrigation group than in the non-irrigation group. CONCLUSIONS: Prophylactic irrigation may possibly be able to prevent the occurrence of pancreatic fistula and infectious complications after a pancreaticoduodenectomy in patients with a risky pancreatic remnant.

The role of the new Ca2+ antagonist, CV159, in hepatic I/R injury-the evaluation of hepatic organ reducing activity using in vivo and ex vivo EPR.

We investigated the organ-reducing ability of 1,2-dihydro-2,6-dimethyl-4-(3-nitrophenyl)-3,5-pyridine-dicarboxylic acid methyl 6-(5-phenyl-3-pyrazolyloxy) hexyl ester (CV159) that exhibits selective blocking of Ca(2+)/calmodulin and inhibition of Ca(2+) overloading in living organisms (Sprague Dawley rats) using an in vivo and an ex vivo electron paramagnetic imaging technique. Decay rates in CV159-treated rats were significantly higher than those in untreated rats and were almost equal to those in the sham group. Both cytosol and mitochondrial superoxide scavenging activity in CV159-treated rats were significantly higher than those in untreated rats, and cytosol superoxide scavenging activity only was slightly higher than that in the sham group. Faint staining for anti-superoxide dismutase antibody was markedly observed in necrotic lesions in the liver of control group. Alanine aminotransferase level in CV-treated rats were significantly decreased as compared with the levels in untreated rats. Electron microscopy showed a decreased number of damaged mitochondria, whereas mitochondrial damage was significantly reduced in CV-treated animals. We conclude that CV159 retains the organ-reducing activity against radicals in hepatic I/R injury that is mediated by the inhibition of Ca(2+) overloading.

Irinotecan-induced apoptosis is inhibited by increased P-glycoprotein expression and decreased p53 in human hepatocellular carcinoma cells.

Irinotecan, a DNA topoisomerase I inhibitor, is widely used in cancer chemotherapy. However, little is known of the mechanisms of its antitumor effects and the development of drug resistance in human hepatocellular carcinoma (HCC). In this study, we investigated the effects of short-term culture with SN-38, the active metabolite of irinotecan, on apoptosis in Huh7 cells. The cells were cultured with SN-38 for 24, 72, and 120 h, and apoptosis was determined using the terminal dUTP nick-end labeling (TUNEL) assay. The expressions of p53, apoptosis-related proteins, and P-glycoprotein (P-gp), a protein conferring the multidrug-resistant phenotype, were analyzed using Western blotting. Induced expression of P-gp was detected using fluorescence microscopy. SN-38 significantly induced apoptosis in Huh7 cells at 24 h. SN-38 also increased the expression of p53, Bax, and caspase-9 and decreased Bcl-xL expression in Huh7 cells. SN-38 decreased p53 expression and increased P-gp expression after 120 h, resulting in inhibition of apoptosis. This inhibition was reversed by the addition of verapamil to the culture medium during 120 h incubation. SN-38-induced P-gp expression was additionally enhanced by p53 decoy oligodeoxynucleotide. The changes in P-gp expression were directly moderated by p53 gene downregulation, suggesting that it plays a role in the mechanism of drug resistance. These results suggest that the accumulation of irinotecan in HCC leads to the development of drug resistance.

A rare case of concomitant huge exophytic gastrointestinal stromal tumor of the stomach and Kasabach-Merritt phenomenon.

BACKGROUND: We report an extremely rare case of concomitant huge exophytic GIST of the stomach and Kasabach-Merritt phenomenon (KMP). CASE PRESENTATION: The patient was a 67-year-old man experiencing abdominal distension since September 2006. A physical examination revealed a 25 x 30 cm hard mass that was palpable in the middle and lower left abdomen minimal intrinsic mobility and massive ascites. Since the admitted patient was diagnosed with DIC, surgery could not be performed. The patient received a platelet transfusion and the DIC was treated. Due to this treatment, the platelet count recovered to 7.0 x 10(4); tumor resection was performed at 16 days after admission. Laparotomy revealed a huge extraluminal tumor arising from the greater curvature of the stomach that measured 25 x 30 cm and had not ruptured into the peritoneal cavity or infiltrated other organs. Partial gastric resection was performed. The resected mass measured 25 x 25 x 20 cm. In cross section, the tumor appeared hard and homogenous with a small polycystic area. Histopathology of the resected specimen showed large spindle cell GIST with >5/50 HPF (high-power field) mitotic activity. The postoperative course was uneventful, and the coagulopathy improved rapidly. CONCLUSION: Since the characteristic of tumor in this case was hypervascularity with bleeding and necrotic lesions, coagulopathy was thought to be caused by the trapping of platelets within a large vasculized tumor mass.

Endocutter no-knife and extraparenchymal control of the main hepatic veins for major hepatectomy.

BACKGROUND/AIMS: Extraparenchymal control of the main hepatic veins (ECHV) and use of vascular staplers are now considered as effective methods to prevent intraoperative hemorrhage and duration of hepatic transection. The aim of the present preliminary study was to investigate whether extraparenchymal control of the hepatic veins combined with inflow occlusion and a new articulating linear stapler without a knife (Endocutter no-knife) were effective for major hepatectomy. METHODOLOGY: Twenty patients with hepatic malignant disease underwent major hepatectomies in which 4 or more Couinaud's segments were removed. Extraparenchymal control of the hepatic veins and Endocutter no-knife were used in 7 (Recent group) of the 20 patients after June 2003. Hemihepatic devascularization before hepatic transection, and intermittent hepatic inflow occlusion were also performed in these 7 patients. In the other 13 (Previous group) patients before June 2003, major hepatectomy was performed under only intermittent hepatic inflow occlusion. Intraoperative blood loss volume, transfusion of packed red blood cells, and duration of hepatic transection were compared between the Recent group and Previous group. RESULTS: Estimated blood loss and number of intraoperative blood transfusion were significantly smaller in the Recent group than in the Previous group. Duration of hepatic transection was also significantly shorter in the Recent group than in the Previous group. CONCLUSIONS: The present preliminary study showed that extraparenchymal control of the hepatic veins and Endocutter no-knife are useful for major hepatectomy.

Desulfurization reactions on Ni2P(001) and alpha-Mo2C(001) surfaces: complex role of P and C sites.

X-ray photoelectron spectroscopy and first-principles density-functional calculations were used to study the interaction of thiophene, H(2)S, and S(2) with Ni(2)P(001), alpha-Mo(2)C(001), and polycrystalline MoC. In general, the reactivity of the surfaces increases following the sequence MoC < Ni(2)P(001) < alpha-Mo(2)C(001). At 300 K, thiophene does not adsorb on MoC. In contrast, Ni(2)P(001) and alpha-Mo(2)C(001) can dissociate the molecule easily. The key to establish a catalytic cycle for desulfurization is in the removal of the decomposition products of thiophene (C(x)H(y) fragments and S) from these surfaces. Our experimental and theoretical studies indicate that the rate-determining step in a hydrodesulfurization (HDS) process is the transformation of adsorbed sulfur into gaseous H(2)S. Ni(2)P is a better catalyst for HDS than Mo(2)C or MoC. The P sites in the phosphide play a complex and important role. First, the formation of Ni-P bonds produces a weak "ligand effect" (minor stabilization of the Ni 3d levels and a small Ni --> P charge transfer) that allows a high activity for the dissociation of thiophene and molecular hydrogen. Second, the number of active Ni sites present in the surface decreases due to an "ensemble effect" of P, which prevents the system from deactivation induced by high coverages of strongly bound S. Third, the P sites are not simple spectators and provide moderate bonding to the products of the decomposition of thiophene and the H adatoms necessary for hydrogenation.

Excessive portal flow causes graft failure in extremely small-for-size liver transplantation in pigs.

AIM: To evaluate the effects of a portocaval shunt on the decrease of excessive portal flow for the prevention of sinusoidal microcirculatory injury in extremely small-for-size liver transplantation in pigs. METHODS: The right lateral lobe of pigs, i.e. the 25% of the liver, was transplanted orthotopically. The pigs were divided into two groups: graft without portocaval shunt (n = 11) and graft with portocaval shunt (n = 11). Survival rate, portal flow, hepatic arterial flow, and histological findings were investigated. RESULTS: In the group without portocaval shunt, all pigs except one died of liver dysfunction within 24 h after transplantation. In the group with portocaval shunt, eight pigs survived for more than 4 d. The portal flow volumes before and after transplantation in the group without portocaval shunt were 118.2+/-26.9 mL/min/100 g liver tissue and 270.5+/-72.9 mL/min/100 g liver tissue, respectively. On the other hand, in the group with portocaval shunt, those volumes were 124.2+/-27.8 mL/min/100 g liver tissue and 42.7+/-32.3 mL/min/100 g liver tissue, respectively (P<0.01). As for histological findings in the group without portocaval shunt, destruction of the sinusoidal lining and bleeding in the peri-portal areas were observed after reperfusion, but these findings were not recognized in the group with portocaval shunt. CONCLUSION: These results suggest that excessive portal flow is attributed to post transplant liver dysfunction after extreme small-for-size liver transplantation caused by sinusoidal microcirculatory injury.

[Comparison of ERCP and MRCP: invasiveness and cost].

The purpose of this study was to compare ERCP and MRCP in terms of invasiveness and cost. A questionnaire regarding patient satisfaction was distributed to 23 ERCP patients and 63 MRCP patients. The practical cost of each examination and total yearly cost for 2002, including medication costs for post-ERCP pancreatitis, were calculated. On a trial basis, the total yearly cost for 2002 was also calculated as a percentage of the cost in 1996. Results of the questionnaire showed that patients tended to favor MRCP over ERCP. In our hospital, the practical costs of MRCP and ERCP were 2063 points and 3964 points, respectively. Medication costs for pancreatitis corresponded to about 3% of the total yearly cost for ERCP. The total yearly costs for both examinations and the medication costs for pancreatitis were about 1,360,000 points. The result of trial calculation with the examination percentage of 1996 was about 1,950,000 points. The results of our study demonstrated that MRCP is a noninvasive examination for patients and that its popularization contributed to a reduction in medical costs. For further popularization of equipment and advanced imaging methods, careful assessment of examination costs is important.

Portal vein pressure is the key for successful liver transplantation of an extremely small graft in the pig model.

In partial-liver transplantation, the use of small grafts sometimes results in graft failure, usually caused by portal hypertension after transplantation (Tx). Portal hypertension after Tx can be decreased with a porto-caval shunt (PCS). The purpose of this study is to clarify the effect of the PCS on extremely reduced-size liver Tx. In a pig model, the posterior segment of 25% of a whole liver was transplanted orthotopically. The pigs were divided two groups: group A, graft with PCS ( n=7), and group B, graft without PCS ( n=7). The PCS was made by means of side-to-side anastomosis of the portal vein and the inferior vena cava. We examined the portal vein pressure, survival rate, regeneration rate of the graft, Ki-67 as an index of cell proliferation, and histological findings, and carried out liver-function tests. In group A, five pigs survived for more than 4 days and the remaining two died of a perforated gastric ulcer on post-operative day (POD) 2. In group B, all pigs except one died of graft failure within 24 h. Portal vein pressure after reperfusion in group A and group B was of statistically significant difference ( P<0.05), 14.2+/-3.2 and 18.9+/-4.7 cmH(2)O, respectively. In group A, the regeneration rate of the graft was 94%, 4 days after Tx, and Ki-67 stained remarkably in the parenchymal hepatocytes. In TEM finding, structure of the sinusoid was also well maintained after Tx. From these results we can conclude that the key to success in liver Tx with extremely small grafts lies in the control of the portal vein pressure.