Traumatic biliary stricture successfully treated by percutaneous transhepatic bile duct dilatation: a case report

A 24 year-old woman complained of obstructive jaundice 24 days after blunt abdominal trauma due to a traffic accident. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a stricture, 15 mm in length, at the common bile duct associated with upper bile duct dilatation. Jaundice was reduced by percutaneous transhepatic cholangio-drainage (PTCD). A 7 Fr-sized PTCD tube was exchanged for a larger-sized catheter for percutaneous transhepatic cholangioscopy expecting gradual dilatation of the stricture. Following the confirmation of satisfactory dilatation of the stricture, the catheter was removed. There was no recurrence of jaundice 16 months later in a follow-up study.

Circadian rhythms of arginine vasopressin and vasoactive intestinal polypeptide do not depend on cytoarchitecture of dispersed cell culture of rat suprachiasmatic nucleus

Dispersed cells of rat suprachiasmatic nucleus were cultured for more than a month with chemically defined medium. Arginine vasopressin and vasoactive intestinal polypeptide in the culture medium showed robust circadian rhythms starting 24 h after the cell dissociation. The two rhythms had similar periods, with a phase-lead of the vasoactive intestinal polypeptide peaks to the arginine vasopressin peak of about 1 h. The two rhythms remained two weeks later, with both peaks appearing at almost the same time, suggesting the synchronization of the two rhythms. Significant differences in cell architecture were detected depending on precoating matrices of culture dishes, which did not affect the circadian rhythms of arginine vasopressin and vasoactive intestinal polypeptide. Antimitotic treatment at the beginning of the culture not only reduced the number, but also changed the type of glial cells developed. The treatment did not interrupt the synchronized arginine vasopressin and vasoactive intestinal polypeptide rhythms until day 31. Early appearance of circadian rhythms indicates that neural networks in the suprachiasmatic nucleus are not necessary for the synchronous release of arginine vasopressin and vasoactive intestinal polypeptide. Glial proliferation is not essential for the generation, expression and synchronization of arginine vasopressin and vasoactive intestinal polypeptide rhythms in the dispersed suprachiasmatic nucleus cell culture.

Circadian oscillation of BMAL1, a partner of a mammalian clock gene Clock, in rat suprachiasmatic nucleus

A superfamily gene which encodes a bHLH (basic helix-loop-helix)/PAS transcription factor, BMAL1, was cloned and sequenced from rat cDNA. A robust circadian rhythm of rat BMAL1 expression was detected by in situ hybridization in the suprachiasmatic nucleus (SCN), the site of the circadian clock, with the highest level at the subjective night. Less prominent and completely reversed circadian rhythms of rBMAL1 mRNA were observed in the piriform and parietal cortices. The hybridization signals of rBMAL1 mRNA were also detected in the olfactory bulb, hippocampus, and cerebellum. Since the product of rBMAL1 was recently demonstrated to dimerize with the protein of a mammalian clock gene, Clock, and the protein complex was shown to bind the E Box in the promoter region of mPer1 (a mouse homologue to Drosophila clock gene, Per), rBMAL1 possibly plays a critical role in the clock mechanism generating the circadian oscillation in rats.

Efficacy of hypothermic perfusion using University of Wisconsin solution in extended hepatectomy with hepatic inflow occlusion in a canine model

This study was designed to elucidate the efficacy of University of Wisconsin (UW) solution for preventing liver injury, when used as a hypothermic perfusate infused into the systemic circulation during extended hepatectomy with hepatic inflow occlusion. Adult mongrel dogs (9.5-17.5 kg, n = 14) were subjected to 75% hepatectomy under 60 min hepatic inflow occlusion. The animals were divided into two groups. The UW group (n = 7) underwent hypothermic perfusion using 4 degrees C UW solution (core temperature of the liver: 12.3 +/- 0.2 degrees C). The control group designated as the Ringer's lactate (LR) group (n = 7) underwent hypothermic perfusion using 4 degrees C LR solution. The perfusate was introduced into the systemic circulation via the hepatic vein. Blood from the hepatic vein was sampled, and alanine aminotransferase, purine nucleoside phosphorylase activities and the ammonia concentration were measured. The 7 day survival rate was higher in the UW group than in the LR group. The parameters of liver function were less significantly altered in the UW group than in the LR group. The plasma ammonia concentration was significantly (P < 0.05) lower 6 h after reperfusion in the UW group than in the LR group. A small volume of hypothermic perfusion of the liver using UW solution was safe if it returned to systemic circulation. Hypothermic perfusion of the liver using UW solution may be effective for preventing hepatic tissue injury during extended hepatectomy with hepatic vascular occlusion.

TAS-301, an inhibitor of smooth muscle cell migration and proliferation, inhibits intimal thickening after balloon injury to rat carotid arteries

The purpose of this study was to determine the efficacy and the possible mechanism of action of a recently synthesized drug, TAS-301 [3-bis (4-methoxyphenyl)methylene-2-indolinone], on intimal formation in comparison with those of tranilast, the clinical efficacy of which was reported earlier. Rat carotid arteries were injured using a balloon catheter. Neointimal thickening, measured 14 days after injury, was reduced by the oral administration of TAS-301 in a dose-dependent fashion (3-100 mg/kg), and the effect of TAS-301 at a dose of 100 mg/kg was significantly greater than that of tranilast (300 mg/kg). Fewer cells were found on the intima of balloon-injured arteries of TAS-301-treated rats than on arteries of tranilast-treated rats. In an in vitro assay, TAS-301 inhibited the migration of smooth muscle cells (SMCs) stimulated by platelet-derived growth factor-BB, insulin-like growth factor-1 or heparin-binding epidermal growth factor-like growth factor. In addition, TAS-301 and tranilast reduced the proliferation of medial and intimal SMCs at 4 and 8 days, respectively, after the injury. In vitro, TAS-301 inhibited basic fibroblast growth factor-induced proliferation of SMCs dose dependently. These findings indicate that TAS-301 shows a higher inhibitory potency on intimal formation than tranilast due to inhibition of both migration of medial SMCs and proliferation of medial and intimal SMCs. Our results suggest that further evaluation of TAS-301 as an inhibitor of postangioplasty intimal thickening is warranted.

Fibrin glue sandwich prevents pancreatic fistula following distal pancreatectomy

Pancreatic fistula is a major form of morbidity following pancreatic resection. We conducted a nonrandomized clinical trial comparing the sealing and sandwich techniques of spraying fibrin glue to prevent pancreatic fistula following distal pancreatectomy. The pancreas was transected with a scalpel to identify and suture the main pancreatic duct and its small branches. In the sealing group, fibrin glue was sprayed over the closed pancreatic stump and sutures. Alternatively, in the sandwich group fibrin glue was sprayed so as to cover and join the cut surface of the pancreatic remnant, which was then held closed with sutures. Altogether 111 patients were included in the study (90 with gastric cancer, 10 with esophageal cancer, and 11 with pancreatic cancer). Patients were nonrandomly assigned to the sandwich or the sealing group. Morbidity was 21.8% for the patients in the sandwich group versus 33.9% in the sealing group. Pancreatic fistulas occurred in 9.0% of the sandwich group versus 26.8% of the sealing group. The incidence of fistula was thus significantly lower in the sandwich group. The incidence of fistula was also significantly lower in the sandwich group for gastric malignancy patients undergoing extended radical lymphadenectomy down to the paraaortic lymph nodes combined with left adrenalectomy. Of the patients with gastric malignancy, pancreatic fistulas occurred in 9.3% of the sandwich group versus 25.5% of the sealing group. The fibrin glue sandwich technique is simple and reliable and should be valuable for complementing other prophylactic methods of preventing pancreatic fistula.

Double cancer in different hepatic lobes: hepatocellular and cholangiocellular carcinoma

BACKGROUND/AIM

Hepatic tumors with elements of both hepatocellular and cholangiocellular carcinoma are occasionally encountered; however, the independent and simultaneous occurrence of different epithelial malignant tumors in different lobes is rare. This is a case report of resected double cancer in different lobes of the liver.

MATERIALS AND METHODS

A 73 year old Japanese man, with hepatic mass and a history of peritonitis and hepatitis, underwent laparotomy and hepatic resection of the posterior inferior and the left lateral segment, and cholecystectomy for cholecystlithiasis with left-sided gallbladder at our hospital in 1991.

RESULTS

The tumor, located in the posterior inferior segment, a yellow-white, round, highly circumscribed mass with a thick capsule, was about 9.0 by 8.0 cm in size. The other tumor located in the left lateral segment, grayish-white on the cut section, was approximately 5.0 by 4.0 cm.

CONCLUSION

In our case, it is unlikely the tumor in the right lobe metastasized to the left lobe and transformed into a different type. The two tumors showed clearly different microscopic features. Improved imaging will increase the frequency and number of double cancer diagnosis. This additional data may shed light on the pathogenesis and etiology of double cancer.

Small ileal neurofibroma causing intussusception in a non-neurofibromatosis patient

Neurofibromas in the small intestine are usually accompanied by von Recklinghausen's disease (neurofibromatosis), and usually originate in the intramuscular plexus of Auerbach. We present here a solitary neurofibroma, which caused an ileocolic intussusception, originating in the submucosal plexus of Meissner in a non-neurofibromatosis patient. To our knowledge, there is no previous report of a neurofibroma originating in the plexus of Meissner. This condition was clearly confirmed by macroscopic and microscopic evaluation.

Long-term effects of niceritrol on serum lipoprotein(a) and lipids in patients with high levels of lipoprotein(a)

The long-term effects of niceritrol on lipoprotein(a) (Lp[a]), lipids, apolipoproteins, and fibrinogen and fibrinolytic factors were evaluated in 20 outpatients who had serum Lp(a) levels higher than 20 mg/dL. The mean ( +/- SE) levels of Lp(a) decreased from 33.6 +/- 2.3 mg/dL to 23.5 +/- 3.5 mg/dL after 12 months of niceritrol treatment (P < 0.01). Serum levels of triglycerides and apolipoprotein E decreased significantly and high-density lipoprotein cholesterol (HDL-C) increased significantly after 12 months (P < 0.05). There were no significant changes overall in fibrinogen and fibrinolytic factors, although fibrinogen concentrations showed a tendency to decrease with treatment. PAI-1 levels decreased significantly (P < 0.05) after 6 months of niceritrol treatment. A significant correlation of percent reduction between Lp(a) and apolipoprotein B levels (P < 0.01) was observed, suggesting that the Lp(a)-lowering effects of niceritrol may be due to niceritrol inhibition of apolipoprotein B synthesis, the major apolipoprotein of Lp(a). The ability of niceritrol to decrease Lp(a) levels and increase HDL-C levels, together with its tendency to lower fibrinogen levels, may help prevent coronary events in patients with high levels of Lp(a).

Surgery for tumor thrombi in the right atrium and inferior vena cava of patients with recurrent hepatocellular carcinoma

This is a report on a 42-year-old woman with a tumor thrombus in the inferior vena cava and the right atrium caused by recurrent hepatocellular carcinoma. The tumor thrombus, which extended from the retrohepatic inferior vena cava into the right atrium close to the tricuspid valve was successfully resected using a cardiopulmonary bypass and total hepatic vascular exclusion. The cardiopulmonary bypass was established by cannulating the ascending aorta, the superior vena cava and the infrarenal vena cava, and was performed under moderate hypothermia and ventricular fibrillation. To reduce the duration of ventricular fibrillation, after the tumor thrombus had been removed from the right atrium into the suprahepatic inferior vena cava through the atriotomy, the atriotomy was closed. The intrapericardial or suprahepatic vena cava was then clamped. The caval tumor thrombus was removed using the total hepatic vascular exclusion technique through a vena cava incision. To reduce total hepatic vascular exclusion time the suprahepatic vena caval clamp was released after the caval tumor had been removed from the suprahepatic vena caval. The infrahepatic vena cava just below the hepatocaval junction was then clamped and the entire tumor thrombus was removed. The vena caval incision was closed without a prosthesis. The total hepatic vascular exclusion and vena caval exclusion times were 10 and 30 minutes, respectively. The ventricular fibrillation and total cardiopulmonary bypass times were 15 and 52 minutes, respectively. The operating time was 9 hours and 30 minutes and the total blood loss was 4,000 ml.

Hepatic encephalopathy due to congenital splenorenal shunts: report of a case

A 76-year-old Japanese woman with hepatic encephalopathy was successfully treated for congenital splenorenal shunts by surgical intervention. The flow volume of the splenorenal shunts was 800 ml/min with a shunt pressure of 9.8 mmHg. The portal pressures before and after the shunt resection were 9 mmHg and 12 mmHg, respectively. The portal flows before and after the shunt resection were 230 ml/min and 470 ml/min, respectively. Therefore, both the hepatic sinusoid and the portal vein might provide good compliance for an increased portal flow volume load after shunt resection.

Peripheral blood T cell subsets as a prognostic factor in gastric cancer

The present study was carried out to find out whether or not peripheral blood T cell subsets predict the prognosis of a gastric cancer patient preoperatively. In this retrospective study, we used preoperative T cell subset data from 34 patients with advanced gastric cancer who had been treated by resection. T cell subsets were measured by single color flow cytometry before surgery. Multivariate analysis, using the Cox proportional hazard model, was adjusted to the CD3 cell count, disease stage, the CD16 cell count and the CD4/CD8 ratio, and suggested CD3 cell count (chi 2 = 4.95, P = 0.026) and disease stage (chi 2 = 9.32, P = 0.002) to be statistically the most independent prognostic factors. Using the hazard ratio, the relative risks of the worst versus the best prognosis were 24.3 for the CD3 cell count and 10 for disease stage. For patients with more than 1483 CD3 positive cells, a longer than average survival time can be expected. The prospective hazard ratio (lambda (t)/lambda 0(t)) of an arbitrary gastric cancer patient can be calculated using the following expression: log(e) (lambda (t)/lambda 0(t)) = -0.00127 (CD3 cell count-1483) +2.31186 (Stage-0.606), where Stage III is assigned a value of 0 and Stage IV a value of 1. The survival curve of an arbitrary gastric cancer patient can also be predicted.

Solitary metastasis from papillary thyroid carcinoma in cirrhotic liver with hepatocellular carcinoma

We report a surgical case of hepatocellular carcinoma and solitary liver metastasis from papillary thyroid carcinoma in different lobes of the liver. The former, located in the right anterior superior segment, and the latter, in the left caudate lobe, were resected simultaneously. The hepatocellular carcinoma was a micro(thin)-trabecular, pseudoglandular type of Edmondson's grade II. The liver metastasis was a papillary carcinoma of follicular variant from the thyroid. This is the first report of hepatocellular carcinoma accompanying a solitary liver metastasis from papillary thyroid carcinoma without metastasis in other organs.

Cardiovascular profile of MPC-1304, a novel dihydropyridine calcium antagonist: comparison with other calcium antagonists

The cardiovascular profile of a novel calcium antagonist, MPC-1304 and its active metabolites were investigated in experimental animals in vitro and in vivo, and were compared with those of other calcium antagonists or nitroglycerin (NTG). The ratio of negative chronotropic/negative inotropic effect of MPC-1304 was 23 times higher than that of nifedipine in paced left and spontaneously beating right atria of guinea pigs. MPC-1304 and nifedipine did not change atrial-His (AH) conduction time or His-ventricular (HV) conduction time at hypotensive doses in open-chest dogs, whereas diltiazem prolonged AH time. MPC-1304 increased coronary blood flow, and strongly decreased myocardial oxygen consumption (MVO2) by decreasing blood pressure (BP) and heart rate (HR) in open-chest dogs. Left ventricular pressure (LVP) was not changed. Contractile force (dp/dt) was slightly increased by its action on afterload. MPC-1304 and nifedipine did not dilate the large coronary artery, but NTG did. MPC-1304 increased blood flow of the peripheral arteries, especially vertebral and CBF in anesthetized dogs. Cerebral blood flow (CBF) also increased. MPC-1304 decreased serum cholesterol levels and the plaque area of the aorta in cholesterol-fed rabbits. Because of this cardiovascular profile, MPC-1304 should be useful in treatment of hypertension as well as angina pectoris.

[Esophageal carcinoma with right aortic arch associated with a vascular ring--a case report]

A 56-year-old man with cancer of the mid-thoracic portion of the esophagus and who had a right aortic arch associated with a vascular ring, underwent esophagectomy and mediastinal lymphadenectomy successfully. A routine chest roentgenogram had revealed the right aortic arch. The entire thoracic esophagus was excised via a left thoracotomy, and the left subclavian artery, which originated from a diverticulum of the right descending aorta was located on the left side of the esophagus, ascending from its posterior aspect. The left subclavian artery and the left arterial duct formed a vascular ring which was interrupted by dividing the arterial duct. Histologically, the resected specimen showed poorly differentiated squamous cell carcinoma of the protruding type, and was classified as stage IV, a2, ly(+), V(-) and na(+). Successful mediastinal lymphadenectomy requires that the surgeon pay careful attention to vascular abnormalities, as well as the pathways of the vagal and recurrent nerves.

[Intraperitoneal administration of cisplatin (CDDP) for advanced or recurrent gastric cancer with peritoneal dissemination]

This study was undertaken in order to evaluate the effect of intraperitoneal administration of CDDP on fourteen patients with peritoneal dissemination of advanced or recurrent gastric cancer. The procedure was used together specific hydration transfusion and diuretics. Two patients showed a complete response and 5 patients a partial response. Following this therapy, 2 patients have survived for more than 6 months. Alimentary symptoms (nausea, vomiting) were found but renal toxicity and serious myelosuppression were not recognized in all patients.

Left ventricular performance at rest and during exercise in patients with dual-chamber pacemakers

In 13 patients with an implanted dual-chamber atrioventricular (AV) demand pacemaker, left ventricular performance was elicited by pacing mode manipulation for study using gated cardiac pool scintigraphy at rest and during exercise. There was no significant difference between DDD and VVI at 70 and 90 beats/min with respect to cardiac output, peak ejection rate or peak filling rate. At 110 beats/min, the cardiac output was greater with DDD as compared to VVI. The peak filling rate was also significantly greater with DDD as compared to VVI (DDD: 3.6 vs VVI: 2.8 EDV/s, p less than 0.05). During exercise the cardiac output was greater with DDD as compared to VVI at the same rate. The peak filling rate during exercise was significantly greater with DDD as compared to VVI (DDD: 3.0 vs VVI: 2.5 EDV/s, p less than 0.01). We conclude that DDD is more beneficial than VVI in maintaining cardiac performance during exercise.

[Urethral indwelling catheter, intermittent self-catheterization and urinary infection]

Once a catheter has been passed into the bladder without contamination, there are several possible routes of subsequent infection during drainage period, such as: 1. Entry of bacteria alongside the catheter in the urethra. 2. Introduced bacteria adhered easily to the indwelling catheter and drainage system and colonized. 3. The catheter tip is covered rapidly by various nutrient materials which becomes a good culture medium of stuck bacteria, which is a supply source of bacteria into the bladder urine. 4. Although the motile bacilli ascend very slowly through the stagnant tube and no bacteria ascend against a slowly moving column, rapid transport of organisms occurs in the swirling fluid caused by the passage of rising air bubbles. 5. Continuous urethral catheter drainage permits an average residual urine volume of 7.3 ml. 6. The catheter destroys the antibacterial defense mechanisms of the urinary bladder. The reasons why in many cases of intermittent self-catheterization (CID) urine becomes sterile despite non-sterile procedure, are as follows. In addition to that CIC has none of the disadvantages of the indwelling catheter, it improves the vesical defense mechanisms deteriorated by high pressure voiding. The number of bacteria reintroduced during catheterization is relatively small and they can be eradicated by usual scheduled catheterization within 4-5 hours without residual urine. CIC must be started before trabeculation or diverticuli are formed, in which bacteria remain. Actual determination of residual urine volume after catheterization will help to prescribe a rational program of CIC.

[A case of early carcinoma of the remnant stomach that developed from gastritis cystica polyposa]

A 64-year-old man with an early carcinoma of the remnant stomach that developed from a gastritis cystica polyposa (GCP) is presented, and the morphology and histogenesis of this rare condition are discussed. This patient had a Billroth II reconstructed remnant stomach for 25 years, and was referred to our attention because of cholecystocholedocholithiasis. In screening an upper gastrointestinal barium study and an endoscopy revealed an irregular-shaped, flat, polypoid tumor in a stoma of the posterior wall. The resected polypoid lesion measured 4.5 x 3.0 cm. A histological examination revealed it to be a well differentiated adenocarcinoma of the mucosal layer that had developed from a GCP.

[A case of duodenal carcinoid associated with early gastric carcinoma]

This case involves a 51-year-old female. In 1983, a gastroscopic examination disclosed a submucosal tumor in the duodenum. In 1986, during follow-up observation, on her visit to hospital an early gastric carcinoma at the antrum was found. Thus, a distal gastrectomy, which entailed the complete removal of the Group 2 lymph nodes and the hepatoduodenal, intra-mesenteric lymph nodes, and Billroth I reconstructive surgery were both performed. A histopathological examination revealed that the antral lesion was a carcinoma, sig. m. ly0. v0. n(-), and that a lesion at the duodenal bulb was carcinoid, with cell that were positive to Grimelius staining and to somatostatin serotonin by an immunological staining. A metastases to the lymph nodes but only along the upper trunk of the common hepatic artery, also was found.