Inguinal hernia repair in patients with artificial urinary sphincter after radical prostatectomy

PURPOSE

Stress urinary incontinence (UI) often develops after radical prostatectomy for prostate cancer, and in those patients with moderate-to-severe stress UI an artificial urinary sphincter (AUS) is implanted. Inguinal hernias (IHs) often occur after radical prostatectomy. As the prevalence of AUS implantation increases, it is possible to encounter patients with IHs undergoing AUS implantation (IHA). This study investigated our treatment and discussed an appropriate approach for IHAs.

METHODS

We retrospectively investigated patients who underwent IH repair with AUS implantation at our hospital from January 2018 to March 2023. We classified IHAs into Types A-D based on the positions of the IHs and AUS devices (the positions of the control pump, pressure-regulating balloon, and connecting tube). The hernia and control pump were ipsilateral in Types A and B, whereas the hernia and pressure-regulating balloon were ipsilateral in Types A and C.

RESULTS

This study included 12 IHs of 11 patients. The median patient age was 77 years. We conducted open repair in nine patients with all types and laparoscopic repair in two patients with Type B. The median operation times for unilateral and bilateral repairs were 96 and 182 min, respectively. There were no complications with AUS or hernia surgeries.

CONCLUSION

IHA has its own characteristics, and multidisciplinary knowledge thereof will help surgeons safely perform IH surgery.

Efficacy of laparoscopic surgery for loop colostomy: a propensity-score-matched analysis

PURPOSE

Colostomy is a common procedure for fecal diversion, but the optimal colostomy approach is unclear in terms of surgical outcomes and stoma-related complications. The purpose of this study was to examine the efficacy and feasibility of laparoscopic loop colostomy.

METHODS

This retrospective cohort study included patients who underwent loop colostomy at Shizuoka Cancer Center in Japan between April 2010 and March 2022. Patients were divided into two groups based on surgical approach: the laparoscopic (LAP) and open (OPEN) groups. Surgical outcomes and the incidences of stoma-related complications such as stomal prolapse (SP), parastomal hernia (PSH), and skin disorders (SD) were compared with and without propensity score matching.

RESULTS

Of the 388 eligible patients, 180 (46%) were in the LAP group and 208 (54%) were in the OPEN group. The male-to-female ratio was 5.5:4.5 in the Lap group and was 5.3:4.7 in the OPEN group, respectively. The median age was 68 years (range, 31-88 years) in the LAP group and 65 years (range, 23-93 years) in the OPEN group, respectively. The LAP group, compared with the OPEN group, had a shorter operative time and lower incidences of surgical site infection (3.9% versus 16.3%, respectively; p < 0.01) and SD (11.7% versus 24.5%, respectively; p < 0.01). There was no significant difference between the LAP and OPEN groups in the incidence of SP (17.3% versus 17.3%, respectively) or PSH (8.9% versus 6.7%, respectively). After propensity score matching, the incidences of surgical site infection and SD were significantly lower in the LAP group than in the OPEN group, while there were no significant differences in the operative time or the incidences of SP and PSH.

CONCLUSION

Our results suggest that laparoscopic surgery could be beneficial and feasible in loop colostomy.

Outcomes of robot-assisted versus conventional laparoscopic low anterior resection in patients with rectal cancer: propensity-matched analysis of the National Clinical Database in Japan

BACKGROUND

Robot-assisted laparoscopic surgery has several advantages over conventional laparoscopy. However, population-based comparative studies for low anterior resection are limited. This article aimed to compare peri-operative results of robot-assisted low anterior resection (RALAR) and laparoscopy.

METHODS

This retrospective cohort study used data from patients treated with RALAR or conventional laparoscopic low anterior resection (CLLAR) between October 2018 and December 2019, as recorded in the Japanese National Clinical Database, a data set registering clinical information, perioperative outcomes, and mortality. Of note, the registry does not include information on the tumour location (centimetres from the anal verge) and diverting stoma creation. Perioperative outcomes, including rate of conversion to open surgery, were compared between RALAR and CLLAR groups. Confounding factors were adjusted for using propensity score matching.

RESULTS

Of 21 415 patients treated during the study interval, 20 220 were reviewed. Two homogeneous groups of 2843 patients were created by propensity score matching. The conversion rate to open surgery was significantly lower in the RALAR group than in the CLLAR group (0.7 versus 2.0 per cent; P < 0.001). The RALAR group had a longer operating time (median: 352 versus 283 min; P < 0.001), less intraoperative blood loss (15 versus 20 ml; P < 0.001), a lower in-hospital mortality rate (0.1 versus 0.5 per cent; P = 0.007), and a shorter postoperative hospital stay (median: 13 versus 14 days; P < 0.001) compared with the CLLAR group. The CLLAR group had a lower rate of readmission within 30 days (2.4 versus 3.3 per cent; P = 0.045).

CONCLUSION

These data highlight the reduced conversion rate, in-hospital mortality rate, intraoperative blood loss, and length of postoperative hospital stay for rectal cancer surgery in patients treated using robot-assisted laparoscopic surgery compared with laparoscopic low anterior resection.

Robotic-assisted multivisceral resection for rectal cancer: short-term outcomes at a single center

BACKGROUND

The safety and feasibility of robotic-assisted multivisceral resection for locally advanced rectal cancer remain unclear. The aim of this study was to assess the short-term outcomes of this procedure at our institution.

METHODS

From December 2011 to December 2016, patients who underwent robotic-assisted multivisceral resection for rectal cancer were investigated. Patient demographics, treatment characteristics, perioperative outcomes, and pathological results were evaluated retrospectively.

RESULTS

There were 31 patients; 17 men (54.8%) and 14 women (45.2%), with a median age of 65 years (range 40-82 years). Twenty-one patients (67.7%) had a cT4 tumor, 9 patients (29.0%) had a pT4b tumor, and all patients except one (96.8%) underwent complete resection of the primary tumor with negative resection margins. Eleven patients (35.5%) received neoadjuvant chemoradiation. The most commonly resected organ was the vaginal wall (n = 12, 38.7%), followed by the prostate (n = 10, 32.3%). Lateral lymph node dissection was performed in 20 patients (64.5%). The median operative time was 394 min (range 189-549 min), and the median blood loss was 41 mL (range 0-502 mL). None of the patients received intraoperative blood transfusions or required conversion to open. Overall, postoperative complications occurred in 11 patients (35.5%). The most frequent complication was urinary retention (n = 5, 16.1%), and none of the patients developed serious complications classified as Clavien-Dindo grades III-V.

CONCLUSIONS

Robotic-assisted multivisceral resection for rectal cancer is safe and technically feasible.

Male sexual dysfunction after rectal cancer surgery: Results of a randomized trial comparing mesorectal excision with and without lateral lymph node dissection for patients with lower rectal cancer: Japan Clinical Oncology Group Study JCOG0212

BACKGROUND

We conducted a randomized controlled trial (JCOG0212) to determine whether the outcome of mesorectal excision (ME) alone for rectal cancer is not inferior to that of ME with lateral lymph node dissection (LLND). The present study focused on male sexual dysfunction after surgery.

METHODOLOGY

Eligibility criteria included clinical stage II/III rectal cancer, the lower margin of the lesion below the peritoneal reflection, the absence of lateral pelvic lymph node enlargement, and no preoperative radiotherapy. After confirmation of R0 resection by ME, patients were intraoperatively randomized. Questionnaires using the International Index of Erectile Function (IIEF-5) about the sexual function of men were collected before and 1 year after surgery. Sexual dysfunction incidence was defined as the ratio of patients showing sexual dysfunction after surgery relative to the number who had no erectile dysfunction before surgery.

RESULTS

Among 701 patients enrolled between June 2003 and August 2010, 472 males were included. Among them, 343 (73%) completed preoperative and postoperative questionnaires. According to the study protocol, the incidences of sexual dysfunction in patients who underwent ME alone and ME with LLND were 68% (17/25; 95%CI, 47-85%) and 79% (23/29; 95%CI, 60-92%), respectively (p = 0.37). Incidences of sexual dysfunction in patients with no or only mild erectile dysfunction before surgery who underwent ME alone and ME with LLND were 59% (48/81) and 71% (67/95), respectively (p = 0.15). Multivariate analysis identified age as the only risk factor for sexual dysfunction after surgery (p = 0.02).

CONCLUSIONS

LLND may not increase sexual dysfunction incidence after rectal cancer surgery. This incidence is associated with increased age. This trial is registered with ClinicalTrials.gov, number NCT00190541 and University Hospital Medical Information Network Clinical Trials Registry, number C000000034.

Randomized clinical trial of skin closure by subcuticular suture or skin stapling after elective colorectal cancer surgery

Background

The best suture method to prevent incisional surgical-site infection (SSI) after clean-contaminated surgery has not been clarified.

Methods

Patients undergoing elective colorectal cancer surgery at one of 16 centres were randomized to receive either subcuticular sutures or skin stapling for skin closure. The primary endpoint was the rate of incisional SSI. Secondary endpoints of interest included time required for wound closure, incidence of wound problems, postoperative length of stay, wound aesthetics and patient satisfaction.

Results

A total of 1264 patients were enrolled. The cumulative incidence of incisional SSI by day 30 after surgery was similar after subcuticular sutures and stapled closure (8·7 versus 9·8 per cent respectively; P = 0·576). Comparison of cumulative incidence curves revealed that SSI occurred later in the subcuticular suture group (P = 0·019) (hazard ratio 0·66, 95 per cent c.i. 0·45 to 0·97). Wound problems (P = 0·484), wound aesthetics (P = 0·182) and postoperative duration of hospital stay (P = 0·510) did not differ between the groups; subcuticular sutures took 5 min longer than staples (P &lt; 0·001). Patients in the subcuticular suture group were significantly more satisfied with their wound (52·4 per cent versus 42·7 per cent in the staple group; P = 0·002).

Conclusion

Compared with skin stapling, subcuticular sutures did not reduce the risk of incisional SSI after colorectal surgery. Registration number: UMIN000004001 (http://www.umin.ac.jp/ctr).

S-1 as adjuvant chemotherapy for stage III colon cancer: a randomized phase III study (ACTS-CC trial)

BACKGROUND

S-1 is an oral fluoropyrimidine whose antitumor effects have been demonstrated in treating various gastrointestinal cancers, including metastatic colon cancer, when administered as monotherapy or in combination chemotherapy. We conducted a randomized phase III study investigating the efficacy of S-1 as adjuvant chemotherapy for colon cancer by evaluating its noninferiority to tegafur-uracil plus leucovorin (UFT/LV).

PATIENTS AND METHODS

Patients aged 20-80 years with curatively resected stage III colon cancer were randomly assigned to receive S-1 (80-120 mg/day on days 1-28 every 42 days; four courses) or UFT/LV (UFT: 300-600 mg/day and LV: 75 mg/day on days 1-28 every 35 days; five courses). The primary end point was disease-free survival (DFS) at 3 years.

RESULTS

A total of 1518 patients (758 and 760 in the S-1 and UFT/LV group, respectively) were included in the full analysis set. The 3-year DFS rate was 75.5% and 72.5% in the S-1 and UFT/LV group, respectively. The stratified hazard ratio for DFS in the S-1 group compared with the UFT/LV group was 0.85 (95% confidence interval: 0.70-1.03), demonstrating the noninferiority of S-1 (noninferiority stratified log-rank test, P < 0.001). In the subgroup analysis, no significant interactions were identified between the major baseline characteristics and the treatment groups.

CONCLUSION

Adjuvant chemotherapy using S-1 for stage III colon cancer was confirmed to be noninferior in DFS compared with UFT/LV. S-1 could be a new treatment option as adjuvant chemotherapy for colon cancer.

CLINICALTRIALSGOV

NCT00660894.

Safety of UFT/LV and S-1 as adjuvant therapy for stage III colon cancer in phase III trial: ACTS-CC trial

BACKGROUND

The Adjuvant Chemotherapy Trial of TS-1 for Colon Cancer (ACTS-CC) is a phase III trial designed to validate the non-inferiority of S-1 to UFT/leucovorin (LV) as postoperative adjuvant chemotherapy for stage III colon cancer. We report the results of a planned safety analysis.

METHODS

Patients aged 20-80 years with curatively resected stage III colon cancer were randomly assigned to receive UFT/LV (UFT, 300 mg m(-2) per day as tegafur; LV, 75 mg per day on days 1-28, every 35 days, 5 courses) or S-1 (80, 100, or 120 mg per day on days 1-28, every 42 days, 4 courses). Treatment status and safety were evaluated.

RESULTS

Of 1535 enrolled patients, a total of 1504 (756 allocated to S-1 and 748 to UFT/LV) were analysed. The completion rate of protocol treatment was 77% in the S-1 group and 73% in the UFT/LV group. The overall incidence of adverse events (AEs) were 80% in S-1 and 74% in UFT/LV. Stomatitis, anorexia, hyperpigmentation, and haematological toxicities were common in S-1, whereas increased alanine aminotransferase and aspartate aminotransferase were common in UFT/LV. The incidences of grade 3 AEs were 16% and 14%, respectively.

CONCLUSION

Although AE profiles differed between the groups, feasibility of the protocol treatment was good. Both S-1 and UFT/LV could be safely used as adjuvant chemotherapy.

Efficacy of adjuvant chemotherapy with S-1 in patients with positive peritoneal cytology (CY1) who underwent R1 surgery

84

Background: In recent TNM classification, positive peritoneal cytology (CY1) is regarded as M1 disease and classified into stage IV. However, the prognosis of the CY1 patients underwent R1 surgery (microscopic residual tumor) is considered to be relatively better than those underwent R2 surgery (macroscopic residual tumor). Adjuvant chemotherapy with S-1 had demonstrated significant survival benefit in stage II and III gastric cancer in Japan. However, the efficacy of adjuvant S-1 in patients with relatively more advanced stage had not been investigated. Therefore, we investigated the efficacy of adjuvant chemotherapy with S-1 in CY1 patients underwent R1 surgery.

Methods: Among the 2,202 patients with gastric cancer treated at our department between September 2002 and July 2009, a total of 105 patients with CY1 and underwent R1 surgery were included in this study. Clinocopathological features and survival were retrospectively analyzed using prospectively registered data base system.

Results: There were 64 male and 41 female patients. The median age was 61 years old. Eighty-five patients had T4a or T4b tumor and 96 patients had lymph node metastasis. Seventy-eight patients had undifferentiated type of tumor. In 83 patients, adjuvant chemotherapy with S-1 had been performed. In the uni-variate analysis, only the extent of lymph node dissection (D2) and the adjuvant chemotherapy with S-1 demonstrated significant survival benefit. In multi-variable analysis using Cox proportional hazarded model, N-factor, extent of lymph node dissection (D2 vs D1), and adjuvant chemotherapy with S-1 were selected as independent prognostic factors. The median survival time and 5-year survival rate in patients underwent R1 resection with D2 lymphadenectomy and adjuvant S-1 treatment were 42 months and 46%, respectively.

Conclusions: In patients with CY1 and underwent R1 surgery, adjuvant chemotherapy with S-1 demonstrated significant survival benefit. In patients with positive peritoneal cytology without other non-curative factors, D2 lymph node dissection and adjuvant chemotherapy using S-1 is recommended.

No significant financial relationships to disclose.

Prognostic value of duodenal invasion length in patients with gastric cancer

24

Background: Duodenal invasion (DI) has been considered as a poor prognostic factor of gastric cancer patients. Not all the patients would be able to undergo curative operation. Neoadjuvant chemotherapy (NAC) may improve the rate of curative operation of these patients. In this study, we investigated whether the length of duodenal invasion preoperative diagnosis can be one of factor to decide indication of NAC.

Methods: A total of 118 gastric cancer patients with clinically evident DI, who underwent laparotomy at our center, were enrolled in this study. 42 patients with DI length 20 mm or longer were categorized into long invasion group (LI), 76 patients with DI length shorter than 20 mm were categorized into short invasion group (SI). Clinicopathologic features, rate of direct invasion and lymph nodes involvement, R0 resection, and survival rate were compared between two groups.

Results: Resection rate was significantly different between two groups: SI group (85.5%; 65/76), LI group (69.0%; 29/42). Direct invasion to adjacent organs was significantly more frequently observed in LI group (21%; 6/29) than SI group (4 %; 3/65, p = 0.02). In LI group, pancreas invasion was observed in all patients except for one patient. Multivariate analysis to predict the adjacent organ invasion revealed that CT diagnosis (p = 0.005) and invasion length (p = 0.01) were selected as risk factors of direct invasion to adjacent organs. There was no significant difference of nodal involvement between LI group (83%; 24/29) and SI group (83%; 54/65 p = 0.99). The 5-year survival rate was 19% in LI group and 43% in SI group (p = 0.23). The number of patients who underwent R0 resection was more frequently in SI group (75.4%; 49/65) than SI group (69.1%; 16/29). The factors of R1 or R2 resection were metastasis of peritoneum or direct invasion to adjacent organs.

Conclusions: In patients with long duodenal invasion, direct invasion to the pancreas was more frequently observed, and resulted in low curative resection rate and poor survival. Preoperative chemotherapy may improve the curative resection rate and survival in these patients. Prospective study is warranted to evaluate the efficacy of NAC for these patients.

No significant financial relationships to disclose.

Amniotic fluid 'sludge' detected in patients with subchorionic hematoma: a report of two cases

Amniotic fluid 'sludge' is defined as the presence of dense aggregates of particulate matter in close proximity to the internal cervical os. It is of clinical significance in asymptomatic patients at high risk for spontaneous delivery, and in patients with preterm labor and intact membranes. Subchorionic hematoma is another ultrasound finding that is associated with a higher incidence of threatened miscarriage and preterm delivery. We report two cases of occurrence of amniotic fluid sludge in patients with previously detected large subchorionic hematoma. In the first case subchorionic hematoma and amniotic fluid sludge were detected by ultrasonography at 13 + 1 and 18 + 6 weeks' gestation, respectively, followed by preterm premature rupture of membranes, placental abruption and emergency Cesarean section. In the second case subchorionic hematoma and amniotic fluid sludge were detected by ultrasound at 11 + 3 and 15 + 5 weeks' gestation, respectively, followed by miscarriage with histological chorioamnionitis. The coincidence of subchorionic hematoma and amniotic fluid sludge in these cases points to a possible connection between these two significant ultrasound findings.

The human tumor-associated antigen RCAS1 in pregnancies complicated by pre-eclampsia

The human tumor-associated antigen RCAS1 (receptor-binding cancer antigen expressed on SiSo cells) is considered to play a role in the escape of tumor cells from immune surveillance and, at the same time, participates in the inhibition of the maternal immune response during pregnancy. The aim of our study was to investigate the expression of tumor-associated RCAS1 protein in the placenta and amniotic membranes and to assess and compare its concentration in amniotic fluid, maternal and cord blood sera in pregnancies complicated by pre-eclampsia. Samples were obtained from women with pre-eclampsia (N=9), pre-eclampsia with IUGR (N=4), normotensive IUGR (N=7) and healthy term controls (N=25) after delivery. Placentas were studied by immunohistochemistry, Western blot analysis and real-time (RT)-PCR. For assessment of RCAS1 protein concentrations in biological fluids, ELISA was performed. RCAS1 mRNA expression in the placentas of pre-eclamptic patients was significantly lower than in controls (p<0.01). The maternal blood serum RCAS1 protein concentration in the pre-eclampsia cases was also significantly lower than in controls (p=0.0207). The other study groups did not differ significantly. This study reveals the possible role of the RCAS1 protein in the development of pre-eclampsia through an immunological pathway.

Histological identification of fascial structures posterolateral to the rectum

BACKGROUND

A comprehensive understanding of fascial structures around the rectum is important for surgeons. Multilaminar fascial structures have provided different interpretations of reliable surgical planes in rectal surgery.

METHODS

Pelvic visceral materials for histological assessment were obtained from 12 male cadavers. Large specimens covering wide areas around the mesorectum were embedded in paraffin, followed by preparation of semiserial horizontal sections and sagittal sections for histological examination.

RESULTS

Histological examination demonstrated a prehypogastric nerve fascia and parietal presacral fascia in the retrorectal multilaminar structure. The parietal presacral fascia seemed to divide into several lateral continuations. The prehypogastric nerve fascia appeared to join the most medial continuation of the parietal presacral fascia, which continued ventrally and communicated with Denonvilliers' fascia. Any fascial structure connecting directly between the fascia propria of the rectum and the parietal presacral fascia (that is, the rectosacral fascia) was not found in sagittal sections.

CONCLUSION

In the retrorectal multilaminar structure, prehypogastric nerve fascia is evident between the fascia propria of the rectum and the parietal presacral fascia. Sharp dissection in front of the prehypogastric nerve fascia according to the histological configuration of the posterolateral fasciae seems reliable.

S100B protein expression in the amnion and amniotic fluid in pregnancies complicated by pre-eclampsia

Our aim was to investigate the expression of S100B protein in the amnion and to assess the amniotic fluid concentration in pregnancies complicated by pre-eclampsia. Samples were obtained from women who developed pre-eclampsia (n = 7), pre-eclampsia with intrauterine growth retardation (IUGR) (n = 4), normotensive IUGR (n = 7) and gestational hypertension (n = 4) during pregnancy and healthy controls who delivered at term (n = 35). To determine the difference in the expression of S100B in the amnion, we performed immunohistochemistry, western blot analysis and RT-PCR. Using enzyme-linked immunosorbent assay (ELISA), we assessed the S100B concentration in amniotic fluid. The S100B mRNA expression in the amnion of pre-eclamptic patients and patients with pre-eclampsia with IUGR was significantly higher than that in the control. The amniotic fluid S100B protein concentration of the pre-eclampsia and normotensive IUGR cases was significantly higher than that of the control. This study shows that amnion could be a source responsible for the increased concentration of S100B in amniotic fluid. In pre-eclampsia, reactive oxygen species (ROS) are generated by oxidative stress. Some pathological conditions that develop during pregnancy and are related to hypoxic stress can affect the elevation of S100B concentration in the amnion.

Signaling pathway and chronotropic action of parathyroid hormone in isolated perfused rat heart

Parathyroid hormone (PTH) activates both adenylyl cyclase and phospholipase C via the PTH-1 receptor. We previously reported that PTH increased heart rate and that this effect was mediated via the pacemaker current (I f ). However, it has been reported that PTH exerts its chronotropic effect via an interaction with adrenergic receptors or via L-type calcium channels. Thus, the objective of the study was to elucidate the exact mechanism of the chronotropic effect of PTH. We tested whether its chronotropic effects could be abolished by inhibitors of the following systems in isolated perfused rat hearts: alpha-adrenergic (prazosin); beta-adrenergic (propranolol); angiotensin II (CV11974); endothelin-1 (TAK044); calcium channel (verapamil); adenylyl cyclase (miconazole); phospholipase C (U73122) or I f (CsCl). In addition, we measured the cyclic adenosine monophosphate level of the heart after PTH administration. Whereas prazosin, propranolol, CV11974, TAK044, verapamil, and U73122 did not inhibit the chronotropic effect of PTH, CsCl or miconazole suppressed it significantly. PTH increased the cyclic adenosine monophosphate level of the atrium but not the left ventricle. These results indicate that the chronotropic actions of PTH are mediated via selective activation of adenylyl cyclase to increase the I f current.

Fragment-specific actions of parathyroid hormone in isolated perfused rat hearts

Different regions within the parathyroid hormone (PTH) molecule are known to have different biological activities. In the heart, the physiological actions of the intact PTH molecule are known as positive chronotropy and coronary vasodilatation. However, it is unclear which region of the PTH exerts which physiological action in the heart. Therefore, to clarify this point, we examined the hemodynamic effect of intact PTH(1-84) and selected PTH analogs, namely, PTH(1-34), PTH(2-34), [Nle8, 18Tyr34]PTH(3-34), PTH(4-34), [Tyr34]PTH(7-34), and PTH(13-34) in isolated perfused rat hearts. Both PTH(1-84) and PTH(1-34) significantly increased heart rate and decreased coronary perfusion pressure. In contrast, neither PTH(2-34) nor [Nle8,18Tyr34]PTH(3-34) increased heart rate, but they did decrease coronary perfusion pressure. Peptides further truncated at the amino terminus, PTH(4-34), [Tyr34]PTH(7-34), and PTH(13-34), had no effect on hemodynamics. Furthermore, the protein kinase A inhibitor H89, but not the protein kinase C inhibitor H7, attenuated the hemodynamic effects of PTH(1-34) or PTH(2-34), while it prevented those of [Nle8,18Tyr34]PTH(3-34). These results clearly demonstrate that the first amino acid of PTH is essential for its chronotropic property whereas the first 3 amino acids of PTH are involved in its coronary vasodilatory action. Furthermore, protein kinase A, but not protein kinase C, appears to be involved in the chronotropic and coronary vasodilatory actions of PTH.

Hazards of hepatic portocholecystostomy in biliary atresia

A hepatic portocholecystostomy (HPC) has been recommended to avoid postoperative cholangitis in the case of a patent distal extrahepatic bile duct (PDEBD) for the treatment of biliary atresia (BA). We investigated the efficacy and clinical problems of HPC in BA. The clinical records of eight patients with BA and PDEBD were reviewed. The diameter of the common bile duct was compared between the patients with BA and PDEBD and age-matched patients with neonatal hepatitis (NH). Five of 8 patients with PDEBD underwent HPC. One patient had to be converted to a cholecystojejunostomy because of common bile duct stenosis at 19 years of age. The other two patients underwent a reoperation by a hepatic portojejunostomy due to poor bile drainage after HPC. Another patient became jaundice-free one month after HPC, but died of sepsis due to bile leakage 3 months thereafter. The mean diameter of the common bile duct in BA with PDEBD was significantly smaller than that of NH (0.76 +/- 0.16 mm (n = 8) in BA vs. 1.90 +/- 0.39 mm (n = 11) in NH, p<0.01). HPC was thus found to be an excellent operative method for preventing postoperative cholangitis in BA, however, many clinical problems still need to be overcome for such a narrow distal duct.

Human pulmonary dirofilariasis presenting as a small nodule with a cavity

A 73-year-old woman had a 4-year history of lung fibrosis from collagen vascular disease. She presented with a complaint of dry cough. A chest radiograph showed a 2-cm solitary pulmonary nodule with a small cavity in the right lower lobe. Preoperatively, we performed computed tomography of the chest and measured tumor markers. Video-assisted thoracotomy was performed because we could not rule out lung cancer. Pathologic analysis confirmed the presence of a granuloma with Dirofilaria immitis. In Japan, the incidence of human dirofilariasis has steadily increased and must be considered in the workup of cavitary pulmonary nodules.

Influence of age on the presentation and outcome of choledochal cyst

PURPOSE

The aim of this study was to identify the most appropriate timing for surgery in newborns with choledochal cysts.

METHODS

The clinical and histological data of 8 newborn cases of choledochal cysts (newborn group) were compared with 45 cases that were diagnosed later than the newborn period (late group).

RESULTS

The mean and standard deviation of age at diagnosis was 0.4+/-0.4 months and 43.4+/-37.8 months in the newborn and late group, respectively. The age at operation was significantly earlier in the newborn group than in the late group (4.9+/-4.5 months v54.7+/-47.0 months). Although no significant difference in the time that elapsed between the operation and the onset of symptoms between the newborn and late groups (4.5+/-4.7 months v11.3+/-21.1 months), the serum bilirubin level (4.6+/-3.8 mg/dL v1.8+/-3.4 mg/dL) and the grade of liver fibrosis (2.0+/-0.8 v1.1+/-0.8) were significantly higher in the newborn group than in the late group.

CONCLUSION

The newborn group should be considered as a special group of patients with different clinical course and pathology than those of the late group, which necessitate the early surgical intervention to prevent progression of liver fibrosis.

Bile ductular proliferation as a prognostic factor in biliary atresia: an immunohistochemical assessment

PURPOSE

The correlation between the histological findings of the intrahepatic biliary epithelium and postoperative bile drainage in biliary atresia (BA) was investigated.

METHODS

The patients with BA were classified into 2 groups, consisting of a good bile drainage group (GBD, n = 14, mean age at initial operation, 57.6+/-18.0 days) and a poor bile drainage group (PBD, n = 11, mean age at initial operation, 86.9+/-42.7 days). Liver specimens from an initial Kasai's operation were examined by immunostaining using anticytokeratin 7 (CK7) antibody and anti-MIB-1 antibody. The number of CK7-positive cells in the bile ductules was microscopically calculated within the 40-microm-thick interstitium along the limiting plate (LP), and the CK7-positive cell number per unit length of the LP was estimated. In addition, the MIB-1 index in bile ductules also was determined.

RESULTS

The number of CK7-positive cells in PBD was significantly higher than that in GBD (167.6+/-45.6 v 117.8+/-32.4/ mm, P<.05). However, the MIB-1 index in biliary cells did not differ between the 2 groups.

CONCLUSION

An increased number of intrahepatic bile duct epithelial cells in liver specimens at the initial operation may be a poor prognostic factor in BA and appears to depend on the duration of bile stasis rather than the degree of bile stasis.

Estimation of normal heart weight in Japanese subjects: development of a simplified normal heart weight scale

To estimate cardiac workload from total heart weight (HW) in persons who have died suddenly, standards of normal HW must be established. We present standards of normal HW for Japanese subjects and propose a simplified scale for calculating normal HW from body height (BH) and body weight (BW). A total of 830 persons (506 male and 324 female) who had died suddenly of unnatural causes were selected for analysis from among persons examined at forensic autopsy at the Jikei University School of Medicine. The HW, BH and BW of each subject were measured. Body surface area (BSA) in square meters was calculated from BH in centimeters and BW in kilograms with Takahira's equation. We found allometric relations between HW and BSA represented by these equations: HW=BSA(1.441) x 168.200 for males and HW=BSA(1.367) x 161.970 for females. For practical use, we developed a simplified scale with which normal HW can be easily and quickly calculated from BH and BW. Our simple technique can be used to estimate normal HW in routine autopsy practice.

Helicobacter pylori infection in postoperative patients with biliary atresia. A benign colonization?

The prevalence of Helicobacter pylori infection in postoperative patients with biliary atresia (BA) was investigated in relation to esophageal varices, portal-hypertensive gastropathy (PHG), and peptic ulcer disease (PUD) in 25 Japanese patients (10 boys and 15 girls) aged from 16 months to 20 years. Gastric biopsy specimens obtained during endoscopy were used for both the rapid urease test and modified Giemsa staining. The patients were classified into three groups according to liver function: 15 in group A (total bilirubin [TB] < 1.0 mg/dl), 7 in group B (1.0 </= TB < 2.0 mg/dl), and 3 in group C (TB >/= 2.0 mg/dl). Esophageal varices were found in 19 patients (60% of group A and all patients in groups B and C) and PHG in 3 group B patients. However, no gastric or duodenal ulcers were found in any case. Only 2 patients (8%) had H. pylori colonization of the gastric mucosa. Both, however, belonged to group A, and the degree of chronic neutrophilic infiltration of the mucosal layer was as mild as that of the other patients. The prevalence of H. pylori infection and PUD in postoperative patients with BA was quite low, and a pathological relationship with the severity of liver disease could not be determined in these patients.

[Significance of full-thickness chest wall resection as a local treatment for sternum metastasis of breast cancer]

Bone metastasis of breast cancer generally tends to be multiple. However, breast cancer frequently metastasizes to the sternum as solitary metastasis. Resection of the sternum was reported to be an effective surgical technique for sternum metastasis which could not be remarkably improved by chemo-endocrine therapy and locoregional recurrent breast cancer invading the skin. A first patient was diagnosed with sternum metastasis invading the skin 44 months after radical mastectomy for breast cancer of stage II. A second patient had breast cancer of stage IV simultaneously with metastases to the sternum and the lung. Only the lung metastasis was successfully controlled by chemo-endocrine therapy, but the sternum metastasis was progressive, following radical mastectomy. Both patients manifested solitary bone metastases and underwent full-thickness chest wall resection. The defect of the chest wall was reconstructed with the mucocutaneous flap using the dorsal latissimus muscle in case 1 and with the abdominal rectus muscle in case 2. Twenty months after the resection of the sternum, the first patient suffered from supraclavicular lymph node metastasis, and the multidisciplinary treatment including radiation therapy was indicated. This therapeutic procedure was effective, and the patient survived for 63 months after resection of the sternum. The second patient has made good progress for six months in maintaining complete remission with chemo-endocrine therapy. These findings suggested that surgical resection was a useful local treatment for solitary sternum metastasis.

[Intraoperative interstitial microwave therapy for recurrent hepatocellular carcinoma of the caudate lobe: a case report]

Microwave tissue coagulation (MTC) therapy was given patients with recurrent hepatocellular carcinoma (HCC) of the caudate lobe of the liver, in which radical surgery for deteriorated liver function was impossible. A total of 40 MTC sessions was applied to two tumors under laparotomy. MTC was administered for 20 seconds in each session. Microwave energy output was 70 watts for 15 mm needle-electrodes and 100 watts for 30 mm electrodes. Alpha-fetoprotein levels in serum had decreased after surgery. Abdominal computed tomography showed no blood flow whatsoever in tumors undergoing MTC. There are fewer limits to the sites and angles for insertion of electrodes under laparotomy. Thus, the surgical approach provides access to all parts of the liver for treatment. We conclude that intraoperative MTC is highly effective in tumor necrosis, and can be a useful local treatment for nonresectable HCC.

The progressive degeneration of interlobular bile ducts in biliary atresia: an ultrastructural study

The ultrastructure of the interlobular bile ducts were observed in hepatic specimens obtained at surgery in ten patients with biliary atresia, in order to investigate the progress of their degeneration over time after the onset of the disease. As an index for the passage of time, the degree of fibrosis in the portal tracts was investigated. Then the ultrastructural features in the interlobular bile ducts were contrasted with the grading of portal fibrosis Generally, the ultrastructural changes of the interlobular bile ducts were more marked in the cases with severe portal fibrosis than that observed in the cases with mild fibrosis. This correlation suggests that the degeneration of the interlobular bile ducts progressively worsens over time after the obliteration of the extrahepatic bile duct.

Influence of surgery for ischemic heart disease on early postoperative left ventricular function

The pre- and postoperative systolic time intervals, hemodynamics and serum catecholamines were studied in 30 patients with successful myocardial revascularization surgery or left ventricular aneurysmectomy and the influence of the surgery on the left ventricular function was evaluated. 1. Significant depression of left ventricular performance was recognized in the group of patients with left ventricular aneurysm as compared to the patients with angina pectoris with or without previous myocardial infarction before the operation. 2. At 2 hours after the operation, signigicant decrease of ET/PEP, cardiac index and stroke work index and marked elevation of systemic vascular resistance were seen in the group of patients with aortocoronary bypass surgery who had previous myocardial infarction and with left ventricular aneurysmectomy as compared to the group of patients without previous myocardial infarction. 3. At 2 hours after the operation, ET/PEP seemed to reflect the left ventricular stroke work and the depression of the left ventricular function was mainly affected by the elevation of systemic vascular resistance due to the hypersecrection of serum catecholamines. 4. Reduction of systemic vascular resistance by vasodilator brought an improvement of EG/PEP, cardiac index and stroke work index.