A small glucagonoma of the pancreas with evident ductular and tubular structures

A 54-year-old woman was admitted to our department for assessment of a tumor of the pancreas found incidentally on abdominal ultrasonography. Examination revealed a hypovascular 1-cm sized tumor in the body of the pancreas. Surgical examination revealed that the tumor was solitary and located in the pancreas body, with no invasion to the adjacent organs iof lymph node involvement. Distal pancreatectomy, preserving the spleen, was performed. Histologically, the tumor was a glucagonoma with evident ductular and tubular structures, suggesting that its site of origin was ductal epithelia.

Acute acalculous cholecystitis with a decrease in CD4/CD8 ratio

Acute acalculous cholecystitis (AAC) usually occurs in the elderly and in those with severe pre-existing pathological conditions. However, there have recently been reports of AAC in relatively young immunosuppressed patients, such as those with acquired immunodeficiency syndrome (AIDS). We report here a 27-year-old woman with AAC who received an emergent cholecystectomy. Although anti-human immunodeficiency virus antibody (anti-HIV) was not detected, a decrease in the CD4/CD8 ratio in sera was found. This rare case of AAC in a patient with decreased CD4/CD8 ratio who showed no other related diseases suggests that surgeons should keep in mind the possible presence of immunosuppression in this condition.

Appleby operation for carcinoma of the body and tail of the pancreas

Long-term survival of carcinomas in the body and tail of the pancreas after surgery is still rare. One of the major reasons for unresectability is cancerous invasion to major vessels, such as the common hepatic and splenic arteries. Resection of the involved arteries can increase resectability and thus might increase post-operative survival. The aim of this study was to clarify the importance of the Appleby operation for carcinoma of the body and tail of the pancreas. A Case Report was carried out with a 54 year-old man, had suffered back pain and loss of body weight for six months. Imaging procedures such as US, CT or angiography showed a carcinoma in the body of the pancreas, about 3 cm in size, and both the common hepatic and splenic arteries were invaded by the tumor. The Appleby operation was used for this patient, since firstly there was no invasion to the head of the pancreas, secondly neither the proper hepatic artery nor the SMA was involved, thirdly the root of the CA was free of carcinoma, and finally because clear pulsation of the proper hepatic artery could be felt one or two minutes after occlusion of the CHA, which indicated that resection of the CHA would not lead to hepatic ischemia. The postoperative course was uneventful. His appetite recovered well and his body weight increased to the level before the disease. The patient was relieved from back pain and has returned to work 18 months after the operation, although he had a local recurrence eight months after the operation. In addition, eleven cases with carcinoma of the body and tail of the pancreas were used for a literature review. The average survival time after the Appleby operation is 6.6 months, and four patients are still alive. One patient has survived 13 years after the operation. It was concluded that although the prognosis after Appleby procedure is still not satisfactory that this operation can at least offer patients a better quality of life.

Renal cell carcinoma of the spindle cell type with metastasis to the pancreas: a case report

We report a case of renal cell carcinoma in a 49-year-old man with multiple metastases, including some to the pancreas which were initially diagnosed as primary pancreatic carcinoma. The first clinical manifestation was jaundice caused by a large metastatic lymph node. Computed tomography showed tumors in the body and tall of the pancreas as well as in the left kidney. Angiography showed that all of the lesions were hypervascular. The patient was finally diagnosed as having renal cell carcinoma. Cholecystectomy and choledochojejunostomy were performed. Intraoperative biopsy of the lymph nodes along the common hepatic artery showed spindle cell carcinoma which was compatible with renal cell carcinoma. Since renal cell carcinoma with pancreatic metastasis is rare, special attention should be paid to its differentiation from primary pancreatic carcinoma in patients with tumors in both the pancreas and kidneys.

Role of hypertriglyceridemia in the pathogenesis of experimental acute pancreatitis in rats

CONCLUSION

The pancreatic damage initiated via different pathogenetic pathways can be increased by triglycerides. Thus, triglycerides seem to play an important role in the pathogenesis of acute pancreatitis.

BACKGROUND

Lipolytic enzymes and their substrates may play a role in the pathogenesis of acute necrotizing pancreatitis. We investigated, therefore, whether triglycerides alter the course of acute pancreatitis in three experimental models of rats.

METHODS

1. Edematous acute pancreatitis induced by repeated sc injections of cerulein; 2. Necrotizing acute pancreatitis by retrograde duct injection of sodium taurocholate; and 3. Pancreatic edema by ligation of: a. The bile duct at the liver hilus; b. The common bile/pancreatic duct close to the duodenal wall; or c. A combination of a. and b. Six hours later, rats were sacrificed and the isolated perfused pancreas prepared. The pancreases were perfused with either HEPES/Ringer/HAES alone or in combination with various concentrations of triglycerides (1-5% wt/vol). The activities of lipase and amylase in the portal venous effluents were regarded as a marker of pancreatic injury. In addition, the pancreases were evaluated by light microscopy.

RESULTS

In both cerulein and taurocholate acute pancreatitis, amylase/lipase activities were significantly higher compared to controls during 45 min of perfusion. In both models, addition of triglycerides caused a dose-dependent marked elevation of enzymes. Ligation (a) did not cause any rise in enzymes in the venous effluent; triglycerides had no effect. Ligation (b) or (c) caused a significant increase of pancreatic enzymes, which was further increased by triglycerides. Histology showed various degrees of severity of tissue damage depending on the model used. The additional damaging effect of a 45-min perfusion with triglycerides, however, could not be detected by histology.

Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein

BACKGROUND

The significance of preserving the spleen has recently been shown. However, there are few reports of spleen-preserving distal pancreatectomy for lesions of the body and tail of the pancreas, and this procedure is not generally performed. The aim of this study was to clarify the technique and indications for spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for benign lesions of the distal pancreas.

METHODS

Four patients (two each with an endocrine tumor and a cystic lesion) underwent the procedure. We also performed the spleen-preserving Puestow's procedure with removal of the tail of the pancreas in a 22-year-old male patient with familial chronic pancreatitis. An important technique is to remove the splenic vein from the pancreas from the body of the pancreas toward the spleen and to remove the splenic artery from the pancreas in the other direction. The splenic vein is identified behind the pancreas and within the thin connective tissue membrane, which is cut longitudinally above the splenic vein. It is important to remove the splenic vein from the pancreas from the body of the pancreas toward the spleen, because it is very difficult to remove it in the other direction. There are many branches from the splenic vein on both sides; these branches should be carefully ligated and cut. The pancreas is removed from the splenic artery from the spleen toward the head of the pancreas. This procedure is much easier than removal of the pancreas from the vein.

RESULTS

The postoperative course was uneventful in four of the five patients. A pancreatic fistula remained in one patient for several weeks. The mean and standard deviation of the operative blood loss, the duration of the operation, and the postoperative hospital stay in the four uneventful cases, excluding the one in which Puestow's procedure was performed, were 600 +/- 479 ml, 290 +/- 48 minutes, and 40 +/- 21 days, respectively. No severe complications occurred in any of the five patients.

CONCLUSIONS

Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein is easy and safe and should be performed for benign lesions of the distal pancreas.

Subtotal resection of the head of the pancreas preserving duodenum and vessels of pancreatic arcade

We reported a procedure of duodenum-preserving subtotal pancreatectomy of the pancreas according to the precise anatomy of the pancreatoduodenal region, especially of the pancreaticoduodenal arteries which provide blood to the duodenum. After a complete Kocher's maneuver is performed, the pancreas is cut above the portal vein and removed from the third portion of the duodenum, followed by the removal of the posterior surface of the pancreas head from a connective tissue membrane. The main pancreatic duct is identified at its junction with the terminal portion of the bile duct from the posterior surface of the head of the pancreas and is cut at the junction. The pancreas is cut in the line of the ASPD. The reason we leave the part of the pancreas between the auodenum, ASPD and the common bile duct is that the artery toward the papilla of Vater runs along the right side of the common bile duct and would be difficult to be preserved with the removal of this part of the pancreas. The most important techniques of this procedure is to keep the connective tissue membrane of the posterior surface of the pancreas intact so as to preserve pancreaticoduodenal arteries and veins. Benign lesions as well as lowgrade malignancy of the head of the pancreas may be possible indications for this procedure.

Functional expression of CD11a on CD8+ cells is suppressed in regional lymph nodes with cancer involvement in patients with gastrointestinal carcinoma

BACKGROUND

To evaluate the immunologic activity of regional lymph nodes, the phenotype of lymphocytes and the functional expression of cell adhesion molecules (CAMs) on lymph node lymphocytes (LNL-: uninvolved, LNL+: involved) were investigated in patients with gastrointestinal carcinoma.

METHODS

The lymphocyte subpopulation and the expression of CD11a, CD44, and CD29 on CD4+ and CD8+ cells in peripheral blood lymphocytes (PBL), LNL- and LNL+ derived from 37 patients with gastrointestinal carcinoma were studied. In addition, the adherence of CD8+ cells to ICAM-1 which reflects the adhesive function of CD11a, was examined, and changes in this adherence were studied by experimental coculture with cancer cells (DLD-1).

RESULTS

Although there were no differences in the overall proportion of T cells between the groups, CD8+ cells and CD16+ cells were considerably diminished in LNL+. The expression of CD11a and CD29 on CD4+ and CD8+ cells was significantly lower in LNL than in PBL, whereas the expression of CD44 showed no significant differences. The expression levels of these CAMs were almost the same in LNL- and LNL+. Only CD11a expression on CD8+ cells in LNL+ was significantly lower than that in LNL- (P < 0.005). The adherence of CD8+ cells in LNL+ to ICAM-1 was lower than that in PBL and LNL-, and was extremely enhanced by experimental coculture with cancer cells (DLD-1).

CONCLUSIONS

These data indicate that the functional expression of CD11a (LFA-1) on CD8+ T cells is suppressed in cancer-involved regional lymph nodes in patients with gastrointestinal carcinoma.

A case of gallbladder cancer with para-aortic lymph node metastasis who has survived more than seven years after the primary extended radical operation

A 55-year-old man with gallbladder cancer was surgically treated in our hospital in July 1988. The tumor was about 8 cm in diameter, replaced the entire gallbladder, and invaded the liver and the hepatoduodenal ligament. In addition, extensive tumor metastasis to lymph nodes, including those of the para-aortic area was noted (Stage IV). Extended cholecystectomy with resection of the liver and lymph node dissection were performed. Although all of the macroscopic tumors were removed surgically, we believed that the tumor would recur in the near future, since all of the excised para-aortic lymph nodes were involved by carcinoma histologically. After surgery, the patient received 5'-deoxy-5-fluorouridine (5'-DFUR) orally at a dose of 600 mg per day. In December 1993, more than 5 years after the primary operation, cancer recurrence in para-aortic lymph nodes was demonstrated by computed tomography (CT). In June 1994, the patient underwent a second operation for treatment of recurrent tumor. The lymph nodes firmly adhered to both the aorta and left renal vein, and could not be removed. Since August 1994, he has received external radiation therapy, and there has been no further enlargement of the nodes. This is the first reported case of gallbladder cancer with para-aortic lymph node metastasis who survived more than seven years after the primary extended radical operation with cholecystectomy, resection of the liver, and extended lymph node dissection.

Mucin-producing adenoma associated with pancreas divisum and hepatic hilar carcinoma: an autopsy case

We present the autopsy case of an 82-year-old Japanese woman with a mucin-producing adenoma accompanied by pancreas divisum and a hepatic hilar carcinoma. She had suffered from a cholangiocellular carcinoma at the hepatic hilus for 2 months, which was treated with radiation and chemotherapy. She did not complain of any abdominal pain. Obstructive jaundice deteriorated despite percutaneous transhepatic bile duct drainage, and she died of hepatic insufficiency. At autopsy, a hepatic tumor was confirmed to have caused severe obstructive jaundice. Histological examinations showed moderately to poorly differentiated cholangiocellular adenocarcinoma with squamous metaplasia, probably due to radiation. A yellowish mucinous tumor was found in the head of the pancreas near the minor papilla. It consisted of multiple rice-sized cystic lesions with thin septa. Although it had no capsule, its margin was clear. Neither a wide opening of the major or minor papilla nor mucous drainage was observed. Gross examinations revealed unfused pancreatic ducts. The slightly dilatated dorsal duct and a branch of the mildly dilatated ventral duct showed tumor involvement. Histological examinations showed mild atypia of the epithelia, and this pancreatic tumor was diagnosed as branch duct-type mucin-producing adenoma with postradiation dysplasia. The combination of a mucin-producing tumor and pancreas divisum is rare, and this is only the third reported case.

Duct-ectatic type of mucin producing tumor of the pancreas--new concept of pancreatic neoplasia

BACKGROUND/AIMS

Although there have been recent reports of mucin-producing tumor of the pancreas, there has been no thorough clinicopathological analysis of a large number of cases.

MATERIALS AND METHODS

Two hundred forty four cases of mucin-producing tumor of the pancreas from Japanese, European and American reports, together with 15 cases of our own, were analyzed clinicopathologically.

RESULTS

Mucin-producing tumor of the pancreas was found in 177 males and 82 females (M:F = 2.2:1). The mean age was 65.5 years. Jaundice, diabetes mellitus and a past history of pancreatitis were found in 15%-19% of the cases. The tumor was most frequently (62%) found in the head of the pancreas. Pathologically, hyperplasia or adenoma was found in 58 cases, and adenocarcinoma in 160 cases. Five-year-survival rate by the Kaplan-Meier method was 82.6% in all of the cases and postoperative survival curve was much better in cases with this type of carcinoma than in cases with ordinary pancreatic duct cell carcinoma (5-year-survival rate: 82.6% vs 17.3%). Serum tumor markers such as CEA or CA 19-9 were not effective in differentiating between benign and malignant, or in determining the degree of cancerous spread, while cytology of the pancreatic juice and biopsy of the tumor could contribute to the diagnosis.

CONCLUSIONS

Mucin-producing tumor has unique clinicopathological characteristics, such as the dilated main pancreatic duct or branches, dilatation of the orifice of the papilla of Vater, or good prognosis. Since a diagnosis for benign or malignant is very difficult in some cases, methods for distinguishing benign from malignant lesions or for determining cancerous spread, such as molecular biological techniques, should be established.

Effects of pancreatic duct ligation and aging on acute taurocholate-induced pancreatitis. Experiments in the perfused pancreas in rats

CONCLUSION

When taurocholate was injected into the common bile duct, high ductal pressure due to ligation of the pancreatic duct did not produce more damage in the pancreas of both old rats and young adult rats, and levels of pancreatic enzymes in portal venous effluent were lower in old rats than in younger rats.

BACKGROUND

The effects of ligation of the pancreatic duct and aging on acute pancreatitis caused by taurocholate are still unclear.

METHODS

Young adult and old male Wistar rats were used. Six hours after ligation of the common bile duct in both the duodenum and liver hilus, rats were killed and the pancreata were perfused. Taurocholate or normal saline was injected retrogradely into the common bile duct. The levels of amylase and lipase in the portal venous effluent were determined as markers of damage to the pancreas. The pancreas was also histologically examined after the perfusion experiments using an Image Analysis System.

RESULTS

(1) A nonsignificant elevation of pancreatic enzymes was found in portal venous effluent by the retrograde injection of saline into the common bile duct. Injection of taurocholate caused a marked elevation of enzymes in the effluent for the first 30 min after injection, which then gradually decreased. (2) Basal levels of pancreatic enzymes were significantly higher in the ligation group than in the nonligation group. Injection of saline into the common bile duct had no apparent effect on enzymes in the effluent. In contrast, taurocholate injection into the common bile duct produced a marked increase in enzymes in the portal venous effluent. However, no significant difference was found between the ligation group and the nonligation group. (3) Similar findings were obtained when old rats were used. (4) Although basal levels of enzymes were almost the same in nonligated old and young adults rats, taurocholate injection into the pancreatic duct in old rats resulted in a significant depression of enzymes compared to that in young adult rats. In the ligation group, pancreatic enzymes in the portal venous effluent following taurocholate injection tended to be lower in old rats than in young adult rats. The results were histologically supported in that various degrees of fibrosis were found in the pancreata of old rats.

A new method of duodenum-preserving subtotal resection of the head of the pancreas based on the surgical anatomy

BACKGROUND/AIMS

Duodenum-preserving resection of the head of the pancreas has been performed for benign and, sometimes, malignant diseases of the pancreas. We propose a new procedure of duodenum-preserving subtotal pancreatectomy of the pancreas according to the precise anatomy of the pancreatoduodenal region, especially of the pancreaticoduodenal arteries which provide blood to the duodenum.

MATERIAL AND METHODS

After a complete Kocher's maneuver is performed, the pancreas is cut above the portal vein and removed from the third portion of the duodenum, followed by the removal of the posterior surface of the pancreas head from a connective tissue membrane. The main pancreatic duct is identified at its junction with the terminal portion of the bile duct from the posterior surface of the head of the pancreas and is cut at the junction. The pancreas is cut in the line of the ASPD. This line is almost the same as the left side of the common bile duct. The ASPD and the common bile duct should be preserved in this procedure.

RESULTS

The reason for leaving part of the pancreas between the duodenum and the anterior superior pancreaticoduodenal artery and the common bile duct is that the artery toward the papilla of Vater runs along the right side of the common bile duct and would be difficult to be preserved with the removal of this part of the pancreas. The most important technique of this procedure is in keeping the connective tissue membrane of the posterior surface of the pancreas intact so as to preserve pancreaticoduodenal arteries and veins, because all the pancreaticoduodenal arteries and veins are situated on this membrane. Complete Kocher's maneuver should cause no problem in this procedure.

CONCLUSIONS

Benign lesions as well as low-grade malignancy of the head of the pancreas may possibly be the indication of this procedure.

[Reproducibility of measurement of intraocular lens location in situ with an anterior eye segment analysis system]

The reproducibility of the measurement (accuracy of repeated measurement) of intraocular lens (IOL) location in situ was studied using an anterior eye segment analysis system (NIDEK EAS-1000). The measurements were performed as follows: (1) errors at photography: 1) errors by the individual photographer 2) errors among three photographers. (2) errors at analysis: 1) errors by individual analysists 2) errors among six analysists. The greatest standard deviation was the accuracy of repeated measurement. Accuracy of repeated measurement (tilt and decentration) was (1) 1) 1.104 degrees, 0.083 mm, (1) 2) 0.866 degrees, 0.072 mm, (2) 1) 0.597 degrees, 0.079 mm, (2) 2) 0.562 degrees, 0.079 mm. From the data obtained in this study, the reproducibility of the EAS-1000 was satisfactory for measurement of IOL location.

Exocrine function of caerulein-induced acute pancreatitis in anesthetized rats

Exocrine function was studied in anesthetized rats that had received two specific doses of caerulein (maximal stimulation and supramaximal stimulation). Male Wistar rats (body weight, 200-250 g) were divided into three groups: the control group (4-h saline infusion), the maximal stimulation group (0.25 microgram/kg per h caerulein for 4 h), and the caerulein pancreatitis group (10 micrograms/kg per h for 4h). Histologically, interstitial edema and cytoplasmic vacuolization were observed only in the caerulein pancreatitis group, with no abnormal findings in the other groups. The volume of pancreatic juice was significantly increased in both the maximal stimulation group and the caerulein pancreatitis group. The protein output and the amylase output in the 1st h of caerulein infusion were also significantly increased, to 459% and 338% in the maximal stimulation group, and to 925% and 1430% respectively, in the caerulein pancreatitis compared to the baseline values. We also found that the pancreatic juice of the caerulein pancreatitis group contained precipitated protein, and high trypsin activity, and protein degradation was confirmed by electrophoresis. These findings were not observed in the other groups. These results strongly suggest that hypersecretion and the appearance of trypsin activity in pancreatic juice plays an important role in the induction of histological changes in this pancreatitis model in anesthetized rats.

Clinicopathological characteristics and surgical procedures for carcinoma of the papilla of Vater

BACKGROUND/AIMS

In the present study, clinicopathological characteristics of carcinoma of the papilla of Vater and suitable operative procedures for treatment were investigated.

MATERIAL AND METHODS

Sixty cases (40 male and 20 female) of resected carcinoma of the papilla of Vater were studied clinicopathologically.

RESULTS

Among the patients, a polypoid type without ulceration and an ulcer-formation type, with regard to the gross appearance, were found in 37 cases and 23 cases, respectively. Submucosal invasion, invasion to the sphincter Oddi, pancreatic parenchymal invasion and lymph node involvement were found more frequently in the ulcer-formation type than in the polypoid type without ulceration. Postoperative survival curves revealed that the prognosis was poor when either lymph node involvement, invasion to pancreatic parenchyma or ulcer formation was found. Local resection was performed in seven cases, in all of whom carcinoma was found histologically in the cut surface of the tumor. This is easily explained by the fact that mucosal spread or interstitial infiltration was frequently found even in cases with carcinoma at a relatively early stage.

CONCLUSIONS

Local resection for carcinoma of the papilla of Vater is inadequate as a curative resection, and pylorus-preserving pancreatoduodenectomy should be the treatment of choice for carcinoma of the papilla of Vater. However, since there were no differences between the postoperative survival curves of patients who underwent pancreatoduodenectomy or local resection, local resection may still be suitable for patients with other major diseases or a poor condition.

Postoperative decentration of three-piece silicone intraocular lenses

PURPOSE

To compare the postoperative decentration of three-piece silicone intraocular lenses (IOLs) with polymide haptics and with polypropylene (PP) haptics and to determine whether the difference was caused by the haptic material.

SETTING

Kimura Eye and Internal Medicine Hospital and Hitani Eye Clinic, Hiroshima, Japan.

METHODS

Using a previously described photographic method, we calculated the postoperative decentration in randomly selected patients who had phacoemulsification and capsular bag implantation of three-piece silicone IOLs. In 64 patients, the IOL had polyimide haptics and in 57, PP haptics. One surgeon performed all the surgery using the same technique.

RESULTS

Mean decentration of IOLs with polyimide haptics was 0.34 mm +/- 0.17 (SD) and of those with PP haptics, 0.48 +/- 0.30 mm. Although follow-up of the polyimide group was longer than that of the PP group (12.8 +/- 5.7 months and 8.7 +/- 4.0 months, respectively), decentration in the polyimide group was significantly smaller (P < .01).

CONCLUSION

The lower rate of postoperative decentration in the IOLs with polyimide haptics was related to the haptic material.

Analysis of small cystic lesions of the pancreas

There have been few reports on (1) the nature and pathogenesis of small cystic lesions of the pancreas, (2) their incidence, age distribution, and location, and (3) their significance as potential precursors of intraductal papillary tumors, mucinous cystic tumors, and duct cell carcinomas.

MATERIALS

Epithelial growth of small cystic lesions in 300 consecutive autopsy cases and in seven cases of small duct cell carcinoma from among 2300 elderly autopsy cases, was evaluated by histopathological analysis. One hundred eighty-six cystic lesions were found in 73 of 300 autopsy cases (24.3%). The incidence of cystic lesions increased with age. Cystic lesions were equally distributed throughout the pancreas. Epithelial atypia was histologically classified into five groups: normal epithelium; papillary hyperplasia without atypia; atypical hyperplasia; carcinoma in situ; and invasive carcinoma. The incidence of each group was 47.5, 32.8, 16.4, 3.4, and 0%, respectively. Epithelia of atypical hyperplasia or carcinoma in situ were more prevalent in small cystic lesions (less than 4 mm in diameter) than in larger lesions (chi-square test, p < 0.05). Epithelia of dilated ductular branches adjacent to cystic lesions showed a similar degree of atypia as the epithelia of the cystic lesions themselves (p < 0.01). Epithelial atypia of the main pancreatic duct was mild in all of the cases but two, and was not related to that of the cystic lesion. Among the seven cases of small duct cell carcinoma, two cases had small cancerous cystic lesions, 4.1 and 5.3 mm in diameter, within the tumor. Small cystic lesions appear to have the potential to progress to malignancy but definitive evidence has not been demonstrated. Additional studies, including molecular biological examinations, are necessary to fully understand the biology of these lesions.

Malignant insulinoma causing liver metastasis 8 years after the initial surgery: report of a case

We report herein a rare case of malignant insulinoma which recurred as multiple liver metastasis 8 years after the initial resection. The patient was a 51-year-old Japanese man who originally presented in 1985 at the age of 43 years suffering from general malaise and syncope. The initial surgery in 1985 involved complete enucleation of a 15 x 13 mm insulinoma located in the uncus of the pancreas. Histopathologically, the tumor was diagnosed as a benign adenoma (insulinoma) which was immunohistochemically stained with only the anti-insulin monoclonal antibody. Macroscopically, there were no signs of either invasion or metastasis. During the subsequent 7 years, he did not show any symptoms or significant abnormality in laboratory data. However, in 1993, the patient again experienced syncope with hypoglycemia and hyperinsulinemia. Ultrasonography revealed multiple echogenic lesions in the liver and a second laparotomy confirmed multiple hepatic metastases from insulinoma, the histopathological findings of which were similar to those of the primary tumor from 8 years before. The patient is currently being treated with streptozotocin and 5-fluorouracil via a catheter in the hepatic artery.

Study of surgical anatomy for duodenum-preserving resection of the head of the pancreas

OBJECTIVE

The authors precisely examined the topography of the duodenum, pancreas, bile duct, and supplying vessels from the perspective of performing duodenum-preserving resection of the pancreatic head.

SUMMARY BACKGROUND DATA

Little has been reported regarding the detailed surgical anatomy that is crucial in this procedure.

METHODS

The authors precisely examined the local anatomy of the pancreas head and duodenum, using materials from 40 autopsy cases.

RESULTS

Arcade formation between the anterior superior pancreaticoduodenal (ASPD) artery and the anterior inferior pancreaticoduodenal (AIPD) artery was found in all of the cases. After departing from the gastroduodenal artery, the ASPD ran toward a point 1.5 cm below the papilla of Vater, then turned to the posterior aspect of the pancreas to joint the AIPD. In 88% of the cases, an arcade was found between the posterior superior pancreaticoduodenal (PSPD) artery and the posterior inferior pancreaticoduodenal (PIPD) artery. The ASPD, AIPD, PSPD, PIPD, or their branches to the duodenum, the bile duct, and the papilla of Vater were not completely buried in the pancreatic parenchyma in any of these cases. Generally, it was easy to dissect the pancreas from the duodenum because of the loose connection. Near the accessory papilla, however, dissection of the vessels was difficult, and the pancreatic parenchyma sometimes was found in the wall of the duodenum. Dissection of the pancreas from the common bile duct and identification of the main pancreatic duct at the junction with the terminal portion of the bile duct were straightforward in all cases.

CONCLUSIONS

It may be possible to remove the head of the pancreas while preserving of the vascular arcades and their branches to the duodenum, the bile duct, and the papilla of Vater.

Pancreatic carcinoma accompanied by pseudocyst: report of two cases

Two cases of pancreatic cancer accompanied by pseudocyst are reported. Case 1 was a 60-year-old man who was admitted to our hospital complaining of left lower abdominal discomfort. A cystic lesion, about 3 cm in diameter, was found in the pancreatic tail by ultrasonography (US) and computed tomography (CT). No signs of chronic pancreatitis were found. At operation, an elastic, hard, white tumor, about 1 cm in diameter, was felt adjacent to the cystic lesion on the duodenal side. Histologically, this tumor was a duct cell carcinoma with an adjacent pseudocyst upstream of the pancreas. Case 2 was a 57-year-old man who complained of back pain and loss of body weight. US and CT examination revealed a cystic lesion, 11 x 7 cm in size, in the tail of the pancreas. Histological examination of the resected specimen revealed both a duct cell carcinoma, 3 cm in size, in the body of the pancreas and a pseudocyst, 9 cm in size. Pseudocysts accompanying carcinoma are thought to develop from obstruction of the pancreatic duct by the carcinoma, followed by intraductal high pressure and disruption of ductules upstream of the pancreas. Thus, we should pay careful attention to pseudocyst of the pancreas, especially when signs of diffuse chronic inflammation cannot be found, to help identify duct cell carcinoma in the early stage. Further detailed examinations of the cyst fluid or pancreatic juice, such as cytology, tumor marker determinations, or establishment of K-ras codon 12 mutation, are needed.

Suppressive effect of basic fibroblast growth factor on transendothelial emigration of CD4(+) T-lymphocyte

The effect of basic fibroblast growth factor (b-FGF), one of the commonest angiogenic factors in various cancer types, on lymphocyte adhesion and transmigration across the endothelial cell monolayer was investigated using human umbilical vein-derived endothelial cells (HUVEC) and type I collagen gel. Forty-eight h exposure of HUVEC with 2 ng/ml b-FGF significantly decreased the basal adhesion of lymphocytes to endothelial cells. The decrease ratio is further enhanced by the addition of shear stress in this assay system. When HUVEC was stimulated for the last 24 h with optimal conditions of recombinant interleukin 1 beta, the percentages of transmigration as well as adhesion were also decreased significantly by the presence of b-FGF. The expression of intercellular adhesion molecule 1 and vascular cell adhesion molecule 1 was down-regulated by b-FGF exposure in both resting and activated conditions by recombinant interleukin 1 beta, supposedly the main reason for this phenomenon. The migrating cells across b-FGF-stimulated HUVEC contained a markedly lower percentage of CD4(+) T-cells than those across non-treated HUVEC, although the 4B4(+)/2H4(+) ratio in CD4(+) T-cell populations did not differ significantly. These facts suggest that the presence of b-FGF in the angiogenic area suppresses lymphocyte emigration, especially that of CD4(+) T-cells, and thus causes insufficient helper function in local immune response. This effect of b-FGF was possibly one of the critical mechanisms by which cancer cells escape from the host immune reactions in the angiogenic stage of tumor development.

Effect of 5-fluorouracil on secretion and synthesis of pancreatic digestive enzymes: studies in isolated pancreatic acini and perfused pancreas derived from normal rats and from rats with acute necrotizing pancreatitis

5-Fluorouracil (5-FU) has been claimed to have beneficial effects in human pancreatitis because of its ability to inhibit protein synthesis and secretion. However, the effect of 5-FU has not been studied in the pancreas of animals in more detail and the data in human pancreatitis are mostly derived from uncontrolled studies. Thus, we studied potential short-term effects of 5-FU on protein synthesis and secretion in isolated pancreatic acini from normal rats and from rats with sodium taurocholate-induced pancreatitis. Furthermore, we used the isolated perfused pancreas, damaged by taurocholate, to study whether arterial perfusion with 5-FU has any beneficial effects. When pancreatic acini were incubated with various concentrations of 5-FU, CCK-8-stimulated amylase secretion was not altered. Furthermore, 5-FU had no short-term effects on protein synthesis. Protein synthesis and secretion was already markedly depressed in isolated pancreatic acini derived from rats with sodium taurocholate-induced pancreatitis. 5-FU did not further decrease protein synthesis or secretion. Retrograde injection of sodium taurocholate in the main pancreatic duct of the isolated perfused pancreas resulted in a steep increase of amylase and lipase in the portal effluate. Arterial perfusion with 5-FU had no influence on enzyme release into the portal blood. We may conclude that our data, derived from experimental pancreatitis in rats, do not encourage investigation of the effect of 5-FU, an anticancer drug with possibly toxic side effects, in human pancreatitis.