Formulation of energy loss in a four-way circular manhole at crossroad

Energy loss at a manhole which is at a junction of storm sewers or combined sewers is important for accurately estimating its discharge capacity. However, even in Japan, the energy loss at the manhole is usually ignored in designing sewers and flood inundation analysis. One of the reasons for the ignorance is difficulty to formulate the energy loss at the manhole because the number of variables which must be considered increases as the number of sewers connected to the manhole increases. The authors have formulated the energy loss of a four-way circular manhole with three inflow sewers and one outflow sewer at crossroad. The formula is applicable only to the equal flow rates in two opposite lateral inflow sewers. In this paper, a new formula for the energy losses is proposed based on experimental data on a four-way circular manhole with different flow rates on three inflow sewers. It shows that the energy losses calculated with it almost reproduce the measured ones.

Sclerosing Esophagitis with IgG4-positive Plasma Cell Infiltration

The patient was a 76-year-old woman who had noticed slight difficulty in swallowing in the 3 years prior to this presentation. Her dysphagia progressed while she was hospitalized following cervical cancer surgery. Esophagogastroduodenoscopy and an esophagram showed circumferential erosion and a stricture of the thoracic esophagus. Esophageal resection was performed; the resected specimens showed a stricture and wall thickening. Histologically, transmural hyperplasia, which consisted of inflammatory granulation tissue with the abundant infiltration of IgG4-positive plasma cells and lymphocytes, was observed. The patient was diagnosed with probable IgG4-related disease. IgG4-related esophageal disease presenting as esophageal lesions alone is a very rare condition.

Transcutaneous monitoring of partial pressure of carbon dioxide during endoscopic retrograde cholangiopancreatography using a double-balloon endoscope with carbon dioxide insufflation under conscious sedation

BACKGROUND AND AIM

A double-balloon (DB) endoscope can be selectively inserted into the afferent loop to carry out endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy, allowing various types of endoscopic treatments for pancreaticobiliary diseases to be successfully carried out. In order to make such a lengthy procedure more comfortable and safe, sedatives and carbon dioxide (CO2 ) insufflation are widely used for gastrointestinal endoscopy. However, these techniques can increase the risk of CO2 retention. Recently, a new sensor for transcutaneous measurement of partial pressure of carbon dioxide (PCO2 ) has been introduced. The aim of the present study was to evaluate the changes in transcutaneous PCO2 (PtcCO2 ) during DB-ERCP with CO2 insufflation under conscious sedation and assess any complications related to sedation and CO2 insufflation.

METHODS

A total of 312 patients underwent DB-ERCP with CO2 insufflation at our hospital between March 2009 and December 2012. The patients were moderately sedated using midazolam with or without pentazocine. PtcCO2 was measured by a non-invasive sensor throughout DB-ERCP in all patients.

RESULTS

The mean peak PtcCO2 during the procedure was significantly higher than the mean PtcCO2 value before and after DB-ERCP. Body mass index, procedure time and dose of pentazocine were significantly higher in the CO2 retention group (peak PtcCO2 ≥ 50 mmHg). CO2 narcosis was observed in one case.

CONCLUSIONS

DB-ERCP with CO2 insufflation under conscious sedation might have the potential to increase the risk of CO2 retention. Hence, non-invasive and continuous PtcCO2 measurement is useful for early detection of hypercapnia.

A proposal of a diagnostic algorithm with validation of International Consensus Diagnostic Criteria for autoimmune pancreatitis in a Japanese cohort

BACKGROUND

Among many diagnostic criteria for autoimmune pancreatitis (AIP), the International Consensus Diagnostic Criteria (ICDC) first enabled us to diagnose and compare type 1 and type 2 AIP, which permitted tailoring individual diagnostic algorithms depending on local expertise. We compared them and validated ICDC with special reference to levels 1 and 2, and proposed a diagnostic algorithm for AIP in Japan.

METHODS

The diagnostic sensitivity of 5 major criteria (ICDC, Korean, Japanese-2011, Asian, and HISORt criteria) was compared, using 61 patients with AIP. Fifty six patients with pancreatic cancer served as a control. Pancreas imaging on computed tomography (CT) and endoscopic retrograde pancreatography (ERP) were independently evaluated by 3 pancreatologists (5, 10, and 20 years of career experience) and each diagnostic criterion of ICDC was validated with special reference to levels 1 and 2.

RESULTS

The sensitivities of 5 major criteria were 95.1% (ICDC), 90.2% (Korean), 86.9% (Japanese), 83.6% (Asian), and 83.6% (HISORt) with 100% of specificity in each. In the evaluation of pancreas imaging, diagnostic sensitivities of combination with CT and ERP in segmental/focal type AIP were significantly higher than single imaging (26% in CT (P < 0.01) or 35% in ERP (P < 0.05) vs 63% in CT + ERP), but not significantly different in the diffuse type.

CONCLUSIONS

Of the 5 criteria, ICDC is the most sensitive and useful for diagnosing AIP. We have proposed a diagnostic algorithm with CT for the diffuse type of AIP, and combination with CT + ERP followed by EUS-FNA for the segmental/focal type.

A case of IgG4-related disease associated with diffuse large B cell lymphoma

In June 2008, a 74-year-old male was diagnosed with IgG4-related disease including histologically proven IgG4-related prostatitis, and then followed as an outpatient. In July 2011, cervical, chest, and abdominal computed tomography (CT) revealed right parotid gland swelling and lymph node enlargement of the supraclavicular, mediastinal, left hilar, porta hepatis, and para-aorta. A biopsy of the right parotid gland was performed, and we diagnosed diffuse large B-cell lymphoma (DLBCL). As malignancies are possible complications for patients with IgG4-related disease, we must be careful in the follow-up of IgG4-related disease patients.

Autoimmune pancreatitis with histologically proven lymphoplasmacytic sclerosing pancreatitis with granulocytic epithelial lesions

Recent histological and clinical studies have suggested the existence of 2 distinct types of autoimmune pancreatitis (AIP): type 1 AIP related to IgG4, exhibiting lymphoplasmacytic sclerosing pancreatitis (LPSP), and type 2 AIP related to granulocyte epithelial lesions (GELs), exhibiting idiopathic duct-centric chronic pancreatitis (IDCP). We herein present a case of type 1 AIP with histologically proven LPSP with GELs. This patient had neither serum IgG4 elevation nor MPD narrowing. In this case, the clinically and histologically atypical findings for type 1 AIP are intriguing.

Genetic variation of vascular endothelial growth factor pathway does not correlate with the severity of retinopathy of prematurity

OBJECTIVE

The aim of this study was to assess the genetic effects of the vascular endothelial growth factor (VEGF) pathway on retinopathy of prematurity (ROP).

STUDY DESIGN

A prospective study from a tertiary center that enrolled 204 Japanese infants (<35 weeks of gestational age (GA)) having no anomalies. ROP developed in 127, but not in 77 infants. The relative severity was defined as non-severe, moderate and severe ROP for GA, based on the staging criteria. VEGF (g.-634G>C, g.+13553C>T) and VEGF-receptor (KDR g.+4422(AC)11 to 14, Flt-1 c.+6724(TG)13 to 23) gene polymorphisms and clinical variables were assessed by uni/multivariate analyses.

RESULT

The frequency of polymorphisms did not differ between ROP and non-ROP patients. The TT genotype of g.+13553 showed a higher odds ratio for non-severe ROP than CC genotype (P=0.006). Multivariate analyses indicated that low birth weight, blood transfusion and respiratory distress syndrome, but not polymorphisms, were the risk factors of advanced ROP (≥ stage 3).

CONCLUSION

A genotype of the VEGF pathway weakly affects the severity of ROP compared with other clinical factors.

The specific linker phosphorylation of Smad2/3 indicates epithelial stem cells in stomach; particularly increasing in mucosae of Helicobacter-associated gastritis

BACKGROUND

The gastric corpus and antrum are believed to contain epithelial stem cells in the isthmus. However, the lack of useful markers has hindered studies of their origin. We explored whether Smad2/3, phosphorylated at specific linker threonine residues (pSmad2/3L-Thr), could serve as a marker for stem cells.

METHODS

Stomachs, small intestines, and colons from Helicobacter felis-infected and noninfected C57BL/6 mice were examined. Double immunofluorescent staining of pSmad2/3L-Thr with Ki67, cytokeratin 8, or doublecortin and calcium/calmodulin-dependent protein kinase-like-1 (DCAMKL1) was performed, and pSmad2/3L-Thr immunostaining-positive cells were counted. After immunofluorescent staining, we stained the same sections with hematoxylin-eosin and observed these cells under a light microscope.

RESULTS

In infected mice, pSmad2/3L-Thr immunostaining-positive cells were significantly increased in the corpus and antrum compared with those of noninfected mice (p < 0.0001). The number of Ki67 immunostaining-positive cells in the corpus and antrum of infected mice was also much greater than in the noninfected mice. Although pSmad2/3L-Thr immunostaining-positive cells were detected among the Ki67 cells, immunohistochemical co-localization of pSmad2/3L-Thr with Ki67 was never observed. pSmad2/3L-Thr immunostaining-positive cells showed immunohistochemical co-localization with cytokeratin 8, but some of them showed co-localization or adjacent localization with DCAMKL1 immunostaining-positive cells. Under a light microscope, pSmad2/3L-Thr immunostaining-positive cells indicated undifferentiated morphological features and were confirmed in the isthmus. In small intestines and colons, pSmad2/3L-Thr immunostaining-positive cells were detected in specific epithelial cells around crypt bases, where the respective putative stem cells are thought to exist.

CONCLUSIONS

We have identified the significant expression of pSmad2/3L-Thr in specific epithelial cells of the murine stomach and have suggested these cells to be epithelial stem cells.

Primary sclerosing cholangitis with elevated serum IgG4 levels and/or infiltration of abundant IgG4-positive plasma cells

Immunoglobin G4-related sclerosing cholangitis (IgG4-SC) is recognized as one of the systemic sclerosing diseases characterized by abundant IgG4-positive plasma cells with effective steroid therapy. On the other hand, primary sclerosing cholangitis (PSC), recognized as a sclerosing cholangitis of unknown origin without steroid efficacy, has been often clinically confused with IgG4-SC. To date, the prognosis of IgG4-SC is unclear, while the prognosis of PSC is well known to be poor. Therefore, it is clinically very important to be able to distinguish IgG4-SC from PSC. However, at the present time it still remains unclear whether PSC may sometimes be misdiagnosed as IgG4-SC or not. Herein, we report three rare cases of PSC with elevated serum IgG4 levels and/or an infiltration of abundant IgG4-positive plasma cells in the liver: a young male with ulcerative colitis (UC), and elderly female and a young female, each with elevated serum IgG4 levels. The first two patients showed infiltration of abundant IgG4-positive plasma cells in the portal area of the liver without response to steroid therapy. From our experiences, we emphasize that some patients with PSC, who do not respond to steroid therapy, show elevated serum IgG4 levels and/or infiltration of abundant IgG4-positive plasma cells, although the mechanism still remains unclear.

Idiopathic duct-centric pancreatitis (IDCP) with immunological studies

A 65-year-old woman with elevated serum levels of pancreatic enzymes was referred to our hospital for further examinations. Abdominal US and contrast-enhanced CT demonstrated swelling of the pancreas body and tail. MRCP and ERCP revealed abrupt ending of the MPD in the pancreas body. Under the suspicion of malignancy, distal pancreatectomy and splenectomy were performed. The histopathological findings showed idiopathic duct-centric pancreatitis (IDCP) with granulocytic epithelial lesions (GEL). As most cases of Japanese autoimmune pancreatitis (AIP) are lymphoplasmacytic sclerosing pancreatitis (LPSP), the present case seems to be helpful to clarify the clinical findings of IDCP in Japan.

Xanthogranulomatous inflammation of the peripancreatic region mimicking pancreatic cystic neoplasm

Xanthogranulomatous inflammation (XGI) is histopathologically characterized by a marked proliferative fibrosis, parenchymal destruction, and infiltration of foamy histiocytes intermixed with other inflammatory cells. Herein, we report a case of a 73-year-old man without symptoms who was initially diagnosed with a pancreatic cystic tumor but later with XGI in the peripancreatic region. Although XGI has been reported to occur in various organs or tissues, such as the gallbladder, kidney, bone, stomach, colon, appendix, lymph nodes, and soft tissues, XGI involving the pancreas or its surrounding tissues is extremely rare. When a pancreatic cystic lesion does not have typical clinicoradiological features of common pancreatic cystic neoplasms, this pathologic condition should be considered in the differential diagnosis.

Effect of rotifers on the stability of aerobic granules

The current study evaluated the effect of rotifers on the stability of aerobic granules. Two sequence batch reactors (SBRs) with airflow rates of 4 (R1) and 6 (R2) 1 min(-1), respectively, were used to develop aerobic granules. Granules were well developed with excellent settleability in terms of SVI30 (sludge volume index,) of about 50 ml g(-1) in both reactors at the beginning. With the outgrowth of rotifers, granules completely disintegrated in R1 around cycle 500 (a cycle was 3 hours). However, after the rotifers disappeared, i.e. cycle 550, granules re-appeared with a slow settling rate in R1 (SVI30: 200-300 ml g(-1)). The rotifers mechanically damaged the structure of granules, resulting in disintegration. However, granules developed under high shear force seem to have strong resistance to rotifers. During re-granulation, a long time lag between the improvements of morphology and settleability suggested that re-granulation resulted from entanglement more than bio-attachment or bio-growth. Additionally, it was confirmed that the ratio of carbohydrate to protein extracellular polymeric substances (EPS) could well indicate the strength of granules. Protein EPS well correlated with the difference between SVI5 and SVI30 in R1, therefore, decreasing protein EPS would increase the compactness of granules.

Comparison of nutrient removal efficiency between pre- and post-denitrification wastewater treatments

A shortage of organic substances (COD) may cause problems for biological nutrient removal, that is, lower influent COD concentration leads to lower nutrient removal rates. Biological phosphorus removal and denitrification are reactions in which COD is indispensable. As for biological simultaneous nitrogen and phosphorus removal systems, a competition problem of COD utilisation between polyphosphate accumulating organisms (PAOs) and non-polyphosphate-accumulating denitrifiers is not avoided. From the viewpoint of effective utilisation of limited influent COD, denitrifying phosphorus-removing organisms (DN-PAOs) can be effective. In this study, DN-PAOs activities in modified UCT (pre-denitrification process) and DEPHANOX (post-denitrification process) wastewater treatments were compared. In conclusion, the post-denitrification systems can use influent COD more effectively and have higher nutrient removal efficiencies than the conventional pre-denitrification systems.

Aerobic granular sludge: a promising technology for decentralised wastewater treatment

In order to evaluate the characteristics of aerobic granular sludge, a sequencing batch reactor, feeding with synthetic wastewater at the organic loading rate of 8 kg COD/m3 d, was employed on the laboratory scale. Granules occurred in the reactor within 1 week after the inoculation from conventional flocculent sludge. Aerobic granular sludge was characterised by the outstanding settling properties and considerable contaminates removal efficiencies. The SVI30 values were in the range of 20 to 40 ml g(-1). However, the sludge volume index of short settling time (e.g. SVI10--10 min) is suggested to describe the fast settling properties of aerobic granular sludge. The potential application in the decentralised system is evaluated from the point view of footprint and high bioactivity. The occurrence of sloughing, resulting from the outgrowth of filamentous organisms, would be responsible for the instability of aerobic granules. The starvation phase should therefore be carefully controlled for the maintenance and stability of aerobic granular sludge system.

Villoglandular papillary adenocarcinoma of the uterine cervix responding to neoadjuvant chemotherapy with docetaxel and cisplatin: a case report

Villoglandular papillary adenocarcinoma (VGPA) of the uterine cervix is a rare neoplasm, and its treatment has rarely been reported. We report a patient with VGPA stage IIA responding to neoadjuvant chemotherapy with docetaxel (60 mg/m2 as an intravenous infusion) and cisplatin (70 mg/m2 as an intra-arterial infusion). At 3 weeks after completing one course of this regimen, the tumor size was reduced from 5.3 x 4.0 cm to 2.0 x 2.0 cm (81.1% reduction), revealed by computed tomography. Accordingly, the patient underwent radical hysterectomy, and there have been no signs of recurrence. Thus, the combination of docetaxel and cisplatin is suggested to be useful for neoadjuvant chemotherapy of cervical adenocarcinoma.

"Proton-pump inhibitor-first" strategy versus "step-up" strategy for the acute treatment of reflux esophagitis: a cost-effectiveness analysis in Japan

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common condition, and acid-suppressing agents are the mainstays of treatment. For the acute medical management of GERD, two different strategies can be proposed: either the most effective therapy, i.e., proton-pump inhibitors (PPIs), can be given first, or histamine H2-receptor antagonists (H2RAs) can be attempted first (the "step-up" approach).

METHODS

A clinical decision analysis comparing the PPI-first strategy and the H2RA-first "step-up" strategy for the acute treatment of reflux esophagitis in Japan was performed, using a Markov chain approach.

RESULTS

The PPI-first strategy was consistently superior to the step-up strategy with regard to clinical outcomes for the patient and with regard to cost-effectiveness (direct cost per patient to achieve clinical success). This superiority was robust within the plausible range of probabilities according to the sensitivity analyses.

CONCLUSIONS

The PPI-first strategy is superior to the H2RA-first "step-up" strategy with regard to both efficacy and cost-effectiveness and therefore, the PPI-first strategy is the preferred therapeutic approach for the acute medical treatment of reflux esophagitis.

Study on generation of oxygen-depleted water based on stochastically changing solar radiation intensity

To examine the generation probability of oxygen-depleted sea water in Hakata Bay, possible 20 time-series of different hourly-solar-radiation intensities were generated stochastically, and a numerical simulation on dissolved oxygen was carried out for each time series. The results of the model calibration followed the seasonal variation of observed water quality well, and generated cumulative-frequency-distribution curves of daily solar radiation agreed well with the observed ones. The simulation results indicated that the exchange of sea water would have a great influence on the DO concentration, and that the concentration could change more than 1 mg/L in a day. This prediction method seems to be an effective way to examine a solution to minimize fishery damages when DO is depleted.

Seasonal variations in growth rate of phytoplankton in Hakata Bay, Japan

Recently, water pollution with high concentrations of organic matter has occurred frequently in Hakata Bay. It is said that a high level of primary production provides much organic matter and affects water quality of the bay, and it is proved by the appearance of phytoplankton throughout the year. In this study, we simulated variations of phytoplankton population with a box-type model using monthly data in a long-term measurement and we analyzed the final growth rate changes of phytoplanktons that explain the conditions for its appearance. Consequently, we found that the final growth rate varies with pattern of half-year periodicity and water temperature and/or ambient nutrient controls the final growth rate to be low every January and July.

Alterations of phospholipase C isozymes in rat cerebral cortex through hyperoxia

The effect of hyperoxia on the level of three phospholipase C (PLC) isozymes (beta1, gamma1, delta1) was assessed in the rat cerebral cortex. When the rats were exposed to 100% oxygen for 60 h, there was a significant reduction in the catalytic activity of low molecular weight phosphotyrosine phosphatase, which was susceptible to activity loss under oxidative stress. The result suggests that oxidative stress is induced in the rat cerebral cortex through hyperoxia. The protein levels of PLC-beta1 and -delta1 were significantly increased in the cerebral cortex where oxidative stress had been induced, although that of PLC-gamma1 was not altered. There was no significant difference in the total PLC activity of the cerebral cortex between hyperoxia and control rats. Using gel filtration chromatography, it was revealed that the PLC-beta1 activity in the cerebral cortex of the hyperoxia rats was higher than that in the control rats, but the PLC-delta1 activity in the former did not differ from that in the latter, despite an increase in the PLC-delta1 protein level. These findings suggest that the PLC-beta1 and -delta1 protein levels of brain tissues are increased by oxidative stress, and that the increased PLC-delta1 molecule is less active.

Cyclin E mRNA overexpression in epithelial ovarian cancers: inverse correlation with p53 protein accumulation

OBJECTIVE

We investigated the relationship between cyclin E mRNA overexpression and p53 protein accumulation in epithelial ovarian cancers.

METHODS

mRNA was isolated and cDNA was prepared from 36 epithelial ovarian tumors (three adenomas, three low malignant potential tumors, and 30 carcinomas), and six normal ovaries. The cyclin E mRNA expression levels relative to an internal control, beta-tubulin, were determined by semiquantitative polymerase chain reaction (PCR). Cyclin E and p53 protein expression in ovarian cancer tissues were examined by immunohistochemistry using the same series of samples. Fisher exact test of significance and an unpaired t test were used for statistical analysis.

RESULTS

Considerable levels of cyclin E mRNA were detected in all normal ovaries and ovarian tumor samples examined by semiquantitative PCR amplification. mRNA levels of cyclin E were significantly higher in nine of 30 (30%) ovarian cancers compared with those in normal ovaries. The immunohistochemical expression of cyclin E protein was confirmed in the nuclei of tumor cells in 13 of 30 (43%) ovarian cancers. p53 protein accumulation was detected in 12 of 30 (40%) ovarian cancers examined. There was a significant inverse correlation between cyclin E mRNA overexpression and p53 protein accumulation (P <.01, Fisher exact test).

CONCLUSIONS

Cyclin E mRNA overexpression frequently occurs in ovarian cancers without p53 protein accumulation. Cyclin E might have an important effect on the development of a limited number of ovarian cancers.

Characteristics of primary production in a eutrophicated bay

The primary production of phytoplanktons provides organic matter in high concentration in eutrophicated Hakata bay in Japan, even during the winter season in spite of low water temperature. Phytoplanktons may have the biological capabilities to maintain activities of photosynthesis under unfavorable conditions, and these capabilities affect water quality in the bays. In this study, characteristics of primary production were analyzed with a simple box-type ecosystem model. We introduced a concept of efficiency for absorption of sunlight energy to our simulation model of water quality to explain rather high growth rates of phytoplanktons in low sunlight intensity. Through simulation with a box model, we found that the efficiency of primary production in winter is higher than that in summer. It was suggested that the organic pollution comes from dissolved organic carbon (DOC) throughout the year and that the DOC is originated from the primary production of phytoplanktons in biological response of the seasonal change of ambient conditions.

Sphingosylphosphorylcholine induces Ca(2+)-sensitization of vascular smooth muscle contraction: possible involvement of rho-kinase

Sphingosylphosphorylcholine (SPC), a sphingolipid, concentration-dependently (1-50 microM) induced contraction and slight elevation of the cytosolic Ca(2+) concentration ([Ca(2+)](i)) in smooth muscle of the pig coronary artery, the result being a marked increase in the force/[Ca(2+)](i) ratio. In alpha-toxin- or beta-escin-permeabilized, but not Triton X-100-permeabilized, vascular strips, SPC induced contraction at constant [Ca(2+)](i) (pCa 6.3) in the absence of GTP, whereas a G-protein-coupled receptor agonist, histamine, required the presence of GTP to induce the contraction. The Rho-kinase blocker, Y-27632 (10 microM) abolished the SPC-induced Ca(2+)-sensitization, without affecting the Ca(2+)-induced contraction. These results suggest that SPC induces Ca(2+)-sensitization of force in vascular smooth muscle, presumably through the activation of Rho-kinase (or a related kinase).

Hepatocellular carcinoma complicated by gastrointestinal hemorrhage caused by direct tumor invasion of stomach

A 65-year-old man with multiple hepatocellular carcinoma (HCC) underwent intra-hepato-arterial chemotherapy (IHAC) through an implantable port over a period of 10 months after transcatheter arterial embolization (TAE) had been performed three times. TAE was performed twice more, and radiotherapy (total dose, 30 Gy; given over a 3-week period) was given for progressive disease in the lateral segment of the liver. Three months after the radiotherapy had finished, the patient suddenly developed melena. Diagnostic imaging revealed gastrointestinal (GI) hemorrhage from HCC invading the stomach, and total gastrectomy and lateral segmentectomy of the liver were performed because the bleeding could not be controlled. The resected specimen disclosed a centrally necrotic tumor that had invaded the lesser gastric curvature and perforated into the lumen. Pathology examination revealed that the HCC had expansively invaded the gastric mucosa, resulting in exposure in the lumen. The possible mechanisms of direct GI invasion by HCC are briefly discussed, with a review of the literature. GI bleeding secondary to involvement by HCC is rare. The enteric radiation injury seems to have been largely responsible for the GI bleeding in this patient.

Adenocarcinoma arising in a tailgut cyst: report of a case

We report herein the unusual case of a 66-year-old woman found to have adenocarcinoma arising in a tailgut cyst. The patient had been observed for 6 months following the discovery of a presacral cystic mass measuring 10 x 9 cm for which she had refused surgery. The serum tumor marker, carcinoembryonic antigen, became slightly elevated, and diagnostic imaging distinctly revealed a tumorous lesion with papillary projection into the cyst lumen. The cystic mass was then excised through the transsacral approach. The pathological findings were compatible with moderately differentiated adenocarcinoma arising in a tailgut cyst. This entity is extremely rare, and only six cases, including our own, have been reported in the English literature. Early complete excision is advised because it is almost impossible to determine for certain whether presacral cystic masses are benign or malignant prior to surgery.

Definition and diagnosis of early cancer of the biliary tract

From the study on correlation between the depth of cancer invasion and the results of surgery, early cancer of the biliary tract may be defined as cancer cell invasion limited to the mucosal or muscularis propria in the case of carcinoma of the gallbladder, and to the mucosal or fibro-muscular layer in the case of carcinoma of the bile duct. With few exceptions, these tumors had no lymph node metastasis, venous invasion, perineural infiltration or involvement of the lymphatic vessels. Since the cumulative 5-year survival rate was 100% after resection of early cancer, the choice of surgical procedures was considered to be extended cholecystectomy for early cancer of the gallbladder, and the standard radical resective operation for early cancer of the bile duct. An accurate diagnosis was not made preoperatively in most cases of early cancer of the biliary tract. The diagnostic approach is discussed, including the recently developed imaging modalities, such as endoscopic ultrasonography and percutaneous transhepatic cholecystoscopy or cholangioscopy.

Surgical treatment of carcinoma of the hepatic duct confluence: analysis of 55 resected carcinomas

We treated 65 patients with carcinoma of the hepatic duct confluence between 1976 and 1991, 57 (87.7%) of whom were treated surgically; of the 57, 55(96.5%) underwent resection. Radical resection was performed at a rate of 50.9%. Procedures for these 55 patients included resection of the extrahepatic bile duct plus hepatectomy (n = 33; 60.0%), and resection of the duct without hepatectomy (n = 22; 40.0%). In addition, the caudate lobe was resected in 28 of these patients, and the portal vein, hepatic artery, or both were resected in 6. The overall operative morbidity was 21.8%; morbidity occurred in 33.3% of patients with hepatectomy, a significantly higher percent than the 4.5% rate in those without hepatectomy (p < 0.05). Operative death occurred in only 1.9%. As the depth of cancer invasion in the bile duct wall advanced, the incidence of tumor spread (e.g., lymphatic permeation, venous invasion, perineural invasion, lymph node metastasis) increased significantly. The prevalence of extramural tumor extensions in a transverse direction was higher than that in the longitudinal direction along the bile duct wall; and the distance from the margin of the primary tumor to the site of tumor extensions along the bile duct wall was much longer on the hepatic side than on the duodenal side. Cancer invasion of the caudate lobe was observed in 36.4%, and invasion at the surgical margins was found more frequently in those without hepatectomy than those with hepatectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Radical operations for carcinoma of the gallbladder: present status in Japan

Based on the histological findings of 1,686 resected cases of gallbladder carcinoma and operative results collected from 172 major hospitals in Japan, the present status of radical operation was assessed with respect to the relationship between the depth of carcinoma invasion and the operative results. The depth of carcinoma invasion was classified into 5 groups, i.e., limited to the mucosal layer (m) in 11.9%, advanced to the proper muscle layer (pm) in 9.8%, extending to the subserosal layer (ss) in 29.6%, serosal involvement (se) in 21.8%, and carcinoma invading the adjacent organs (si) in 26.9%. Tumor extension, such as lymph node metastasis, invasion of lymphatic and venous vessels, and perineural infiltration, were observed more frequently in patients with ss, se, and si than in those with m and pm. The cumulative 5-year survival rates were 82.6% and 72.5% in patients with m and pm, which were significantly higher than 37.0%, 14.7%, and 7.5% in those with ss, se, and si, respectively. The choice of operative procedures should depend on the depth of carcinoma invasion. Cholecystectomy alone is done only in patients with tumor limited to the mucosa, and more radical procedures such as extended cholecystectomy should be performed in those with carcinoma invasion beyond the mucosa. Pancreatoduodenectomy is indicated in those with lymph node metastasis posterior to the head of the pancreas and with invasion to the duodenum. When the tumor directly invades the liver, major hepatic resection is recommended.(ABSTRACT TRUNCATED AT 250 WORDS)