Clinical usefulness of CA-19-9 in pancreatic carcinoma

Preoperative and postoperative serum levels of carbohydrate antigen-(CA)19-9 in 148 patients with carcinoma of the pancreas were studied. All 18 patients with carcinoma of the pancreas of Stage I, II, and III were resectable, and their pre-operative serum levels of CA-19-9 were under 1,344 U/ml. Pre-operative serum levels of CA-19-9 in patients with Stage IV ranged widely between 5 and 32,240 U/ml. The postoperative survival rate was significantly superior in patients (n = 15) whose CA-19-9 pre-operative serum levels were less than 2,000 U/ml compare to those (n = 64) whose levels were over that level. Fifteen resectable patients who showed serum levels of CA-19-9 over 2,000 U/ml pre-operatively died within 2 years postoperatively due to recurrence, especially by liver metastasis in spite of aggressive surgery. Intraoperative quick immunostaining of CA-19-9 and carcinoembryonic antigen (CEA) was useful to diagnose intrapancreatic carcinoma development on frozen sections of cut margin of the pancreas and also useful in abdominal washing cytology combined with conventional staining.

Interactions: timing and force control of finger-tapping sequences

This study examined effects of combinations of intertap interval and muscle force on interactions between two factors in sequences of equally paced finger taps. 12 male college students tapped a force plate connected to strain gauges. Subjects firstly tapped the plate at a preferred pace and force for 12 sec. Next, subjects tapped the plate by half or double the preferred pace. A series of finger-tapping tasks the consisted of nine combinations of pace and force. Analysis showed that, although variations in intertap interval were considerably accurately controlled across conditions, those in peak forces were not. Movement timing of tapping sequences hence appeared to be independent of force control. For six of 12 subjects, on the other hand, positive correlations between spontaneous variations in intertap interval and in forces were noted. Then, although motor timing was independent of force control in controls of low pace and weak forces, there were strong interactions between the two factors under high pace conditions.

[Outcome of emergency surgery for Stanford type A aneurysms: selection of operative procedures and supported systems of cerebral protection]

Fourteen surgical cases of acute dissecting aneurysms of Stanford type A were reported. Clinical symptoms, operative methods, pathophysiology, cerebral protection, supported systems, and prognosis were examined. All patients underwent surgery within 5 days of symptom onset. The patient population consisted 8 males and 6 females with a mean age of 56.6 years. Ascending aortic replacement was performed using a vascular graft 12 patients. ECC was performed under deep hypothermia. Femoral artery cannulation and retrograde cerebral perfusions was performed in all cases. The ascending aorta was the site of entry in 13 of the 14 cases. Whenever feasible, enhanced CT and aortography were performed to confirm the entry lesion. Two patients expired. One patient died intraoperatively due to massive bleeding. The other patient, while hospitalized, experienced a cerebrovascular accident and died due to pneumonia. All other patients ran an uneventful post-operative course without cerebrovascular accident. In conclusion we think that although ascending aorta replacement using prosthetic grafts is not ideal for patients with Stanford type A dissecting aneurysms, it is a viable option for emergency cases. We found retrograde circulatory cerebroplegia (RCCP) to be satisfactory for brain protection during these emergency procedures.

[Successful removal of a giant ball thrombus in the left atrium in an aged patient with unusual course]

A case of left atrial ball thrombus associated with severe mitral stenosis was reported. This male patient, aged 78, came in the chief complaint of leg and facial edema. An echocardiographic examination revealed the presence of mitral stenosis and floating giant ball thrombus in the atrium. He suffered from acute thromboembolism in his right leg six years ago and had been treated with anticoagulant since then. Despite this a floating giant ball thrombus was observed. Emergency operation including mitral valve replacement and thrombectomy was successfully performed. Thrombus formation in the left atrium is not uncommon but it is very rare to encounter in patients receiving anticoagulant therapy. To manage these patients well, meticulous attention must be paid during induction of anesthesia, intra-operative procedures, perioperative care, and operative position.

[Dor operation for end-stage ischemic cardiomyopathy]

Endoventricular circular patch plasty (Dor operation) was used to treat end-stage dilated ischemic cardiomyopathy in 13 patients from January to December, 1997. There were 10 men and three women aged from 57 to 78 years (mean 63 years). Single, double, triple and left main trunk coronary disease was present in one, two, eight and two patients, respectively. Mean ejection fraction was 22% (6-30%) and signs of congestive heart failure were clear in all patients [New York Heart Association (NYHA) class III in eight patients and class IV in five patients]. Angina pectoris was present in five patients. Six patients had associated significant mitral regurgitation. Coronary artery bypass grafting (mean 3.2 grafts) was used in 11 patients and mitral valve reconstruction was performed in 6 patients (4: replacement and 2: repair) combined with akinetic area exclusion by the Dor technique. All patients were successfully weaned from cardiopulmonary bypass without mechanical support and no perioperative death occurred. Three patients died in hospital at 1-2 postoperative months due to pneumonia, stroke and heart failure, respectively. Two patients died during the late period due to stroke and sudden death. Among the eight survivors, six patients were in NYHA class I-II and two patients in class III. Ejection fraction increased from 22% to 36%, end-diastolic and systolic volume indices decreased from 168 +/- 58 to 123 +/- 39 ml/m2 and from 131 +/- 60 to 81 +/- 33 ml/m2, respectively. Pulmonary capillary wedge pressure decreased from 19 +/- 10 to 14 +/- 5 mmHg. The Dor procedure is an effective surgical alternative for patients with end-stage ischemic cardiomyopathy who are considered to be candidates for cardiac transplantation.

Left ventriculoplasty: a new option for end-stage cardiomyopathy

To treat end-stage dilated cardiomyopathy, we have performed volume reduction left ventriculoplasty (as introduced by Randas Batista in Brazil) in four patients since December 1996. All patients had end-stage idiopathic cardiomyopathy. Mitral valve replacement was also performed in three patients. In all four patients, improvement of left ventricular function was noted. One patient died of respiratory failure on the 12th postoperative day. The other three patients recovered successfully from the operation (i.e., they were discharged from hospital with the functional status in New York Heart Association Class I or II). We conclude that the Batista operation provides a real hope for patients with end-stage dilated cardiomyopathy.

[Early result of volume reduction left ventriculoplasty (Batista operation) for dilated cardiomyopathy]

The Batista operation is intended to improve cardiac function by reducing the diameter of the left ventricle by excising of a sizable amount of the left ventricular free wall. Candidates for this operation are patients awaiting cardiac transplantation due to end-stage dilated cardiomyopathy and those unsuitable for transplantation because of age, physical or economical reasons. We performed this operation in 10 patients between December 1996 and October 1997. The baseline indication is left ventricular diastolic dimension > or = 70 mm and New York Heart Association (NYHA) class III or IV. There were eight men and two women aged from 16 to 60 years (mean 46 years). All had non-ischemic cardiomyopathy including seven idiopathic and one each of hypertrophic, arrhythmogenic right ventricular and valvular (sarcoidosis) cardiomyopathy. Eight patients were in NYHA class IV and six needed inotropic drip therapy prior to the operation. Nine patients had significant mitral regurgitation and six had tricuspid insufficiency concomitantly. Eight patients underwent mitral valve replacement and one was treated with mitral valve plasty. Six patients also had tricuspid plasty combined with partial left ventriculectomy. Eight patients survived. Mean value of left ventricular end-diastolic diameter was reduced from 77.8 mm to 59.8 mm, left ventricular end-diastolic volume index was reduced from 189.3 to 99.2 ml/m2, ejection fraction was increased from 19.0% to 33.8% and NYHA class improved from 3.8 to 1.8. Six months later, left ventricular dilatation was not noticed in four patients examined. The Batista operation offers real hope for patients with end-stage dilated cardiomyopathy, but we still have much to learn.

Application of transmission scan-based attenuation compensation to scatter-corrected thallium-201 myocardial single-photon emission tomographic images

A practical method for scatter and attenuation compensation was employed in thallium-201 myocardial single-photon emission tomography (SPET or ECT) with the triple-energy-window (TEW) technique and an iterative attenuation correction method by using a measured attenuation map. The map was reconstructed from technetium-99m transmission CT (TCT) data. A dual-headed SPET gamma camera system equipped with parallel-hole collimators was used for ECT/TCT data acquisition and a new type of external source named "sheet line source" was designed for TCT data acquisition. This sheet line source was composed of a narrow long fluoroplastic tube embedded in a rectangular acrylic board. After injection of 99mTc solution into the tube by an automatic injector, the board was attached in front of the collimator surface of one of the two detectors. After acquiring emission and transmission data separately or simultaneously, we eliminated scattered photons in the transmission and emission data with the TEW method, and reconstructed both images. Then, the effect of attenuation in the scatter-corrected ECT images was compensated with Chang's iterative method by using measured attenuation maps. Our method was validated by several phantom studies and clinical cardiac studies. The method offered improved homogeneity in distribution of myocardial activity and accurate measurements of myocardial tracer uptake. We conclude that the above correction method is feasible because a new type of 99mTc external source may not produce truncation in TCT images and is cost-effective and easy to prepare in clinical situations.

Increased lung uptake of iodine-123-MIBG in diabetics with sympathetic nervous dysfunction

Scintigraphy with 123I-MIBG and 201TI was compared in patients with various diseases including diabetes mellitus, with and without sympathetic nervous dysfunction. This study was done to assess lung uptake of these tracers semiquantitatively.

METHODS

Thirty-eight patients with diabetes mellitus, seven patients with dilated cardiomyopathy (DCM), 12 patients with hypertrophic cardiomyopathy (HCM) and eight healthy subjects were studied. Sympathetic nervous dysfunction was observed in 13 of the 38 diabetic patients. Simultaneous imaging with 123I-MIBG and 201TI was performed. The ratio of lung to total injected dose count and washout rate in the lung were calculated from dynamic images acquired in the initial 2 min and static images acquired at 15 min and at 4 hr after injection of the tracers.

RESULTS

Lung uptake of 123I-MIBG at 4 hr was significantly increased in the diabetic group as compared with those in the other groups. In diabetic patients with sympathetic nervous dysfunction, the lung uptake ratio of 123I-MIBG at 4 hr was significantly higher than that in the diabetic patients without sympathetic nervous dysfunction, due to decreased clearance of 123I-MIBG from the lung. On the other hand, increased lung uptake of 201TI was observed in DCM patients at both 15 min and 4 hr. There was no significant difference between lung uptake of 201TI in diabetic patients and that in healthy subjects.

CONCLUSION

Lung uptake of 123I-MIBG was increased and lung washout of 123I-MIBG was decreased in diabetic patients with sympathetic nervous dysfunction, while lung uptake of 201TI was not altered. lodine-123-MIBG scintigraphy of the lung may provide information on sympathetic nervous activity in diabetic patients. It is a promising method for studying the kinetics of norepinephrine in the lung because MIBG is taken up in the lung by the same mechanism as norepinephrine.

[Determination of energy window width and position for the triple energy window (TEW) scatter compensation method]

Since primary photons can provide information concerning the position of radioisotope (RI) accumulation and the energy of the photons, it would seem reasonable to vary the position and width of the energy window depending on the type of RI and the energy resolution of the detector to collect as many of the primary photons as possible. We propose a method for determining energy window width and position for scintigraphic imaging to collect as many of the primary photons as possible, and studied the influence on the Triple Energy Window (TEW) scatter compensation method of setting such energy window levels for 99mTc (single photopeak) and 201Tl (multiple photopeaks) using detector with different energy resolution through simulation. The Monte Carlo simulations were verified by comparing the regional energy spectrum at the phantom obtained from the simulation against experimental measurements. The energy window with our proposed method for 99mTc is 20% and 47.3% for 201Tl using gamma camera, and 9.8% for 99mTc using a semiconductor detector with a theorized energy resolution of 7.0 keV.

Promotion of rat hepatocarcinogenesis by dimethylarsinic acid: association with elevated ornithine decarboxylase activity and formation of 8-hydroxydeoxyguanosine in the liver

Arsenicals are epidemiologically significant chemicals in relation to induction of liver cancer in man. In the present study, we investigated the dose-dependent promotion potential of dimethylarsinic acid (DMAA), a major metabolite of inorganic arsenicals in mammals, in a rat liver carcinogenesis model. In experiment 1, glutathione-S-transferase placental form (GST-P)-positive foci, putative preneoplastic lesions, were employed as endpoints of a liver medium-term bioassay for carcinogens (Ito test). Starting 2 weeks after initiation with diethylnitrosamine, male F344 rats were treated with 0, 25, 50 or 100 ppm of DMAA in the drinking water for 6 weeks. All animals underwent two-thirds partial hepatectomy at week 3 after initiation. Examination of liver sections after termination at 8 weeks revealed dose-dependent increases in the numbers and areas of GST-P-positive foci in DMAA-treated rats as compared with controls. In experiment 2, ornithine decarboxylase activity, which is a biomarker of cell proliferation, was found to be significantly increased in the livers of rats treated with DMAA. In experiment 3, formation of 8-hydroxydeoxyguanosine, which is a marker of oxygen radical-mediated DNA damage, was significantly increased after administration of DMAA. These results indicate that DMAA has the potential to promote rat liver carcinogenesis, possibly via a mechanism involving stimulation of cell proliferation and DNA damage caused by oxygen radicals.

[Successful emergency surgical management following cardiac massage in a patient with acute myocardial infarction due to total obstruction of the left main trunk]

The prognosis in patients manifesting shock following acute myocardial infarction due to total occlusion of the left main trunk (LMT) is usually very poor and so is the lifesaving rate. Accurate judgement and rapid response are key to the successful management of this disease. We experienced a successful case with emergency coronary artery bypass grafting (CABG) on the 14 the day after initial attack. The patient, who had total occlusion of LMT, underwent a PTCA (percutaneous transluminal coronary angioplasty) during the initial attack under cardiac massage. We think in situations where patients have cardiac arrest, shock, elevated CPK levels suggesting devastation of myocardium due either to LMT or severe triple vessels disease, early catheter intervention rather than emergency CABG would be much more tolerable as long as hemodynamic situation allows. Our previous experience taught us that immediate surgical intervention with CABG usually resulted in poor outcome. Further refinements regarding the surgical procedure, technique, assist circulatory supports, cardioplegia, etc., are indispensable before trying to have a successful emergency CABG.

[Antitumor effect of S-1 and cisplatin treatment against human gastric cancer xenografted in nude mice]

The enhanced effects due to the combined use of oral administration of S-1 and intraperitoneal administration of Cisplatin (CDDP) were examined with gastric cancer xenografts (NUGC 4). S-1, a new anticancer drug, was daily administered at 10 mg/kg (qld x 5 x 3 weeks). 5-FU level in blood was 1 microgram/ml at two hours after the treatment. Antitumor activity was not found in mice with only the CDDP treatment. But antitumor activity by S-1 and daily low-dose (1 mg/kg) or intermittent treatment (5 mg/kg) of CDDP showed better results than daily S-1 treatment. The daily low-dose CDDP treatment showed similar efficacy to the intermittent administration at the same total dose, but the daily low-dose CDDP treatment was better in the light of toxicities. These results suggest that treatment with S-1 and daily low-dose CDDP was effective for gastric cancer.

The omental flap with skin grafting for treatment of a difficult sternal closure

A case report of difficult sternal closure is described. Chest closure following cardiac operation in critically ill patients can be a problem. Techniques have been described so that sternal closure can be delayed until the patient is hemodynamically stable and hemostasis has been achieved. However, in some instances, the sternal closure can not be performed because of prolonged cardiopulmonary instability. We describe the use of transposition of an omental flap with skin grafting in a 74-year-old patient with aortic valve stenosis, poor pulmonary function, and a thoracic deformity. This technique enabled incomplete sternal closure which maintained hemodynamic stability.

Overcoming of multidrug resistance by VA-033, a novel derivative of apovincaminic acid ester

We have studied the effects of a novel derivative of apovincaminic acid ester, VA-033, on the resistance of tumors to chemotherapeutic agents. VA-033 increased the sensitivity of drug-resistant cell lines (P388/VCR, P388/ADM, AD10, and K562/ADM) to adriamycin or vincristine. The potency of VA-033 was stronger than verapamil. The drug lengthened the survival time of the P388/VCR-implanted mice treated with vincristine. VA-033 increased the intracellular accumulation of vincristine in the tumor cells, and the photolabeling of P-glycoprotein by [3H]azidopine was inhibited by VA-033. VA-033 showed a slight inhibitory effect on the L-type Ca2+ current in the ventricular myocytes, and had less effect on the cardiovascular parameters such as blood pressure, contractile force and atrio-ventricular conduction time than verapamil when administered systemically in the dog. These results suggest that VA-033 may become a beneficial compound as a modifier to the neoplastic cell resistant to multidrugs.

[New surgical procedure for patients with dilated heart and end-stage cardiac failure (Batista procedure)]

A 53-year-old man with dilated cardiomyopathy underwent left ventriculoplasty (Batista procedure), a new surgical procedure, which reduces ventricular volume to improve left ventricular function. Left ventricular ejection fraction increased from 19.7% to 43.7%. Unfortunately, he died of pneumonia 12 days after surgery. This is the first such procedure in a human in Japan.

Quantitative analysis of scatter- and attenuation-compensated dynamic single-photon emission tomography for functional hepatic imaging with a receptor-binding radiopharmaceutical

A new method for quantitative liver study was developed using the tracer technetium-99m diethylene triamine penta-acetic acid-galactosyl human serum albumin (99mTc-GSA), an analog ligand of the asialoglycoprotein receptor, which is a hepatocyte surface receptor specific for galactose-terminated glycoproteins. For quantitative dynamic single-photon emission tomographic (SPET) studies, attenuation compensation using transmission computed tomography (TCT) and the triple energy window (TEW) scatter compensation method were evaluated. As the TCT source, we used an uncollimated multi-tube source with the TEW scatter compensation method. To verify the accuracy of cross-calibrated SPET values as compared with measured radioactivities, we performed SPET of a cylindrical water pool phantom which contains seven hot rods filled with different concentrations of 99mTc activities, simulating the scan conditions in human studies. The results of the phantom studies showed good linearity and accuracy of the SPET values, with R2=0.993 and a regression line of y=0.941x+5.48. From the analysis of a kinetic model based on a one-compartment model, focussing on the initial stage of several minutes after 99mTc-GSA injection and taking the physiological expression presented in a three-compartment analysis into account, we introduced the Rutland equation (Patlak plot) in the 99mTc-GSA study by which the overall and regional effective hepatic blood flow (EHBF) and hepatic blood pool volume were determined. Preliminary clinical evaluations were performed for four normal male subjects (23-35 years of age) and one patient. Forty sequential 30-s dynamic SPET acquisitions were obtained for a period of 20 min following the intravenous injection of 99mTc-GSA with venous blood sampling at 10 min. After scatter compensation, the SPET images were reconstructed with attenuation compensation using an attenuation map obtained from TCT. The average normal value for the total EHBF was 468+/-83 ml/min and that for the hepatic blood pool volume, 777+/-123 ml. Functional images of the distribution of regional values of EHBF (ml/min/voxel) and hepatic blood pool volume (ml/voxel) were also generated corresponding to the original SPET images. The EHBF images showed regional liver function, higher in the right lobe than the left lobe in the normal cases, and the heptic blood pool volume images showed the distribution of intensified high values along major vascular structures. Receptor imaging with 99mTc-GSA using the Rutland method and dynamic SPET with scatter and attenuation compensation is an effective technique that allows the evaluation of total and regional hepatic functional parameters (EHBF, hepatic blood pool) in vivo.

Scatter and attenuation correction in technetium-99m brain SPECT

We propose a practical method for scatter and attenuation compensation in 99mTc-ECD brain SPECT using a simultaneous emission CT (ECT) and transmission CT (TCT) acquisition system that includes the following major components: (a) triple-headed SPECT gamma camera equipped with fanbeam collimators; (b) external line sources containing 99mTc placed at the focal lines of the collimators; and (c) scatter correction by the triple-energy-window (TEW) method.

METHODS

Projection images were obtained over a 360 degrees rotation scan. After acquisition, scatter correction was performed using the TEW method, which corrected scattered photons pixel by pixel in the projection data. Scatter-corrected ECT images were compensated for attenuation using the TCT images with Chang's iterative method, and were converted to activity concentration (kBq/ml) images by obtaining a cross-calibration scan. After validating this method with phantom studies, it was applied to clinical brain imaging using a combination of 925 MBq 99mTc-ECD as a radiopharmaceutical and 222 MBq 99mTc as an external source. ECT and TCT data were acquired separately or simultaneously.

RESULTS

SPECT quantification and image quality were improved by performing this correction. The activity concentration images obtained with the simultaneous acquisition were almost identical to those obtained with the separate acquisition.

CONCLUSION

This method was clinically practical and cost-effective for reconstructing quantitative 99mTc brain SPECT images.

A case of small cell carcinoma of the stomach

A case of small cell carcinoma of the stomach is reported. A 53-year-old male was referred to our hospital for elective surgery for gastric cancer. Pre-operative examinations revealed no metastases. Gastrectomy was performed curatively, and there were no gross findings of metastases. Histologically, the tumor was composed of intermediate-sized cells with hyper-chromatic nuclei and scanty cytoplasm. These cells were argyrophilic and positive for chromogranin A. A small portion of the tumor consisted of conventional adenocarcinoma (signet ring cell carcinoma and tubular adenocarcinoma). No lymph node metastasis was observed microscopically. However, 7 months after the operation, splenic and hepatic metastases were detected, and the patient died very soon thereafter. Small cell carcinoma of the stomach is a very rare disease. In literature, only 15 cases have been cured surgically. Among them, only one case had been diagnosed as small cell carcinoma before the operation, which suggests the difficulty of pre-operative diagnosis. The prognosis of this disease is very poor compared with the common type of gastric carcinoma. Considering the poor prognosis of this particular disease, adjuvant chemotherapy might be mandatory in all cases even if surgically curative resection is performed.

Neoadjuvant chemotherapy in scirrhous cancer of the stomach using uracil and tegafur and cisplatin

We administered a mixture of uracil and tegafur (UFT)/cisplatin (CDDP) chemotherapy in 28 patients with scirrhous gastric cancer. In the regimen, UFT was orally administered at a dose of 200 mg/m2 twice a day. The CDDP was administered at a dose of 90 mg/m2 by 24-hour continuous infusion every 4 weeks. As a result, antitumor effects for primary gastric foci were achieved in 14 of the 28 patients (50%). Ascites from peritoneal dissemination disappeared completely in eight of 13 patients (62%). Total gastrectomy was performed in ten patients after 2 to 3 courses of chemotherapy. Histological response grades assessed on the resected specimen were Grade 2 in four, Grade 1b in three, Grade 1a in one and Grade 0 in two patients. Neoadjuvant chemotherapy is feasible against scirrhous gastric cancer and a subsequent prospective randomized trial should be prepared to clarify the survival benefit of the treatment.

Evaluation of SPET quantification of simultaneous emission and transmission imaging of the brain using a multidetector SPET system with the TEW scatter compensation method and fan-beam collimation

A gamma camera system which is able to acquire simultaneous single-photon emission tomographic (SPET) data and gamma ray transmission computed tomography (TCT) data for brain study using external rod sources and fan-beam collimators was developed and evaluated. Since the three external rod sources were located at the focal points of fan-beam collimators, which also happened to be the apexes of the equilateral triangle defined by the three detectors, simultaneous SPET and TCT scan could be performed using a 120 degrees shared scan. Therefore, the proposed system required less than one-third of the scanning time of a single-head system. Since the combination of rod sources and fan-beam collimators decreased the scatter component in transmission data without a slit collimator for each rod source, the radioactivity of the rod source was less than one-tenth of the previous investigations. For evaluation, we used two isotopes, thallium-201 for TCT and technetium-99m for SPET. The cross-contamination of transmission and emission was well compensated using the triple energy window (TEW) method. In a separate TCT scan, the measured attenuation coefficient of 201Tl for water was 0.19+/-0.01 cm-1, while in a simultaneous scan, it was 0. 20+/-0.01 cm-1. The measured attenuation coefficient for water agreed well with the narrow-beam (theoretical) value of 0.187 cm-1. In SPET images, scatter compensation was also performed using the TEW method and attenuation compensation was done using the measured attenuation map. The results showed the feasibility of simultaneous SPET and TCT scanning using the TEW method to obtain quantitative SPET images.

A new isopatulin derivative pintulin produced by Penicillium vulpinum F-4148 taxonomy, isolation, physico-chemical properties, structure and biological properties

During our screening program of natural products from fungal metabolites for drugs effective against tumor cell lines, we discovered a new isopatulin derivative, pintulin, from the fermentation broth of Penicillium vulpinum F-4148. Pintulin shows weak activity against tumor cell lines, compared to that of adriamycin.

Malignant lymphoma of the gastric stump developing 25 years after a distal gastrectomy for benign gastric disease: report of a case

We report herein the case of a 57-year-old man in whom malignant lymphoma originating in the gastric remnant was confirmed 25 years after a subtotal gastrectomy with Billroth II reconstruction had been performed for gastric ptosis. Gastroscopy revealed an ulcerated tumor on the fornix, and histologic examination of the endoscopic biopsy specimens demonstrated malignant lymphoma. Thus, total gastrectomy with splenectomy, pancreatectomy, and resection of the previously anastomosed jejunal stoma were performed. Histologic examination of the stomach remnant confirmed a diagnosis of B-cell lymphoma of the large-cell type. Although we were unable to study the surgical specimen from the initial operation, the possible relationship between pseudolymphoma and malignant lymphoma has been presented in the literature, which is reviewed following this case report.

[Scatter and attenuation correction for quantitative myocardial SPECT imaging]

We performed scatter and attenuation compensation in 201Tl myocardial SPECT using the triple-energy-window (TEW) scatter correction method and 99mTc transmission scan (TCT). A dual-headed SPECT gammacamera system equipped with parallel-hole collimators was employed for imaging and a sheet source for TCT was attached to the surface of one of the two detectors. Two imaging protocols, a sequential mode and a simultaneous mode, were examined. In the sequential mode, TCT was performed prior to the administration of the tracer and then ECT was carried out. On the other hand, the injection was followed by a simultaneous transmission-emission scan, in the simultaneous mode. Results of phantom studies showed that reconstructed SPECT values of the whole myocardium were almost equal to the true value with errors of less than 5 per cent, and that more homogeneous images were obtained by performing scatter and attenuation correction. We conclude that this correction method was clinically practical and cost-effective because it uses parallel-hole collimators and does not require fan-beam collimators which may produce truncation artifacts.

The importance of the real-time fluoroscopic intraoperative direct cholangiogram in the laparoscopic cholecystectomy using a new instrument

BACKGROUND/AIMS

Laparoscopic cholecystectomy (LC) has become an accepted standard operative technique for gallstone treatment worldwide. On the other hand, complications, such as bile duct injuries, have been reported recently with the expansion of indication for LC. Intraoperative cholangiogram (IOC), to minimize the risk of bile duct injury, is now considered to be essential for safe LC. There are disadvantages to IOC such as increased operating time, the possibility of bile duct injury and the difficulties of manipulation.

MATERIAL AND METHODS

We have developed a method for real-time fluoroscopic cholangiograms using a new instrument designed by our group for safe LC. First, a round-tip stylet is inserted through a sheath to coax it gently through the spiral valves of the cystic duct. Secondly, the stylet is removed and the cholangiogram catheter is inserted smoothly. Digital C-arm fluoroscopy provides "real-time" imaging of biliary tree. As a result, we became able to obtain a clear cholangiogram easily in a very short time.

RESULTS

In the first 136 patients, direct cholangiograms were attempted in 106 cases and successfully completed in 102 cases (96.2%).

CONCLUSION

With the development of real-time fluoroscopic intraoperative direct cholangiogram, we are able to cope with bile duct injuries and anomalies, and unsuspected bile duct stones.