Journal of hepato-biliary-pancreatic surgery最新文献

Background/purpose: In this article we investigate whether a gallbladder flap could be used for reconstruction of the common bile duct (CBD), thereby providing drainage via an intact sphincter of Oddi.

Methods: Eight LWD pigs were used for the experiments. The gallbladder was dissected from its fossa, care being taken not to damage its vessels. The CBD was then displayed and approximately 5 mm resected. In two pigs a tube, and in six pigs a sphere, was constructed from the gallbladder flap. Anastomoses were constructed between the gallbladder flap and the CBD. Blood samples were drawn and on day 10 a laparotomy and an intraoperative cholangiography was performed.

Results: No pigs showed any sign of biliary leakage and standard liver parameters were not affected by surgery. In the two pigs who had a tube constructed, cholangiography showed extrahepatic stenosis and intrahepatic biliary dilatation. In the six pigs who had a sphere constructed, cholangiography was without any sign of extrahepatic stenosis or intrahepatic dilatation.

Conclusion: Reconstruction of the CBD by way of a gallbladder flap seems to be a safe procedure to accomplish biliary drainage. This procedure could be of clinical significance for reconstruction of the CBD after resections for benign strictures and tumors, and for reconstruction after blunt or penetrating trauma. In this article we investigate whether a gallbladder flap could be used for reconstruction of the common bile duct (CBD), thereby providing drainage via an intact sphincter of Oddi.

Although clear cell carcinoma has been found in various organs, only six cases have been reported in the pancreas. Moreover, the histogenesis of clear cell carcinoma of the pancreas remains controversial. We report a case of clear cell carcinoma of the pancreas in a 61-year-old woman, with an unusual pheno- or genotype detected by histochemical, immunohistochemical, and K- ras oncogene analyses. Histologically, the pancreatic tumor was predominantly composed of clear cell nests with scanty fibrous stroma and scattered duct-like structures. Neither clear cell nor duct-like components of the tumor showed mucin production. Immunohistochemical analysis of neoplastic cells showed a positive reaction to antibodies against cytokeratins 8 and 19, carbohydrate antigen 19-9, and alpha-1-antitrypsin, and showed no reaction to antibodies against carcinoembryonic antigen, neuroendocrine markers, trypsin, amylase, and HMB45. K- ras analysis revealed no mutation at codon 12 in either clear cell or duct-like components. The patient has had no recurrence as yet. The pancreatic carcinoma in our patient may be of duct cell origin, but the results of histochemical, immunohistochemical, and gene analyses and patient's outcome were unusual compared with those of previous cases.

We report the case of a 54-year old woman who presented with a persistent right lower lobe pneumonia followed by cholelithoptysis, 11 months after a laparoscopic cholecystectomy. It is postulated that this was a result of the formation of a subphrenic abscess secondary to intraoperative spillage of gallstones. It is concluded that spillage of gallstones at laparoscopic cholecystectomy is not as benign as previously thought and that efforts to prevent spillage should include scrupulous operative technique, especially in the presence of gallbladder inflammation, and especial care when removing the gallbladder from the abdominal cavity.

We experienced a resected case of a small hepatocellular carcinoma, which required differential diagnosis from intrahepatic cholangiocellular carcinoma. The patient was a 76-year-old man. While his course had been being observed because of hepatitis C antibody-positive liver cirrhosis, ultrasonographic examination of the abdomen revealed dilation of biliary branches in the anterior segment of the liver and a hyperechoic mass 10 mm in diameter at the origin of the branch. A dynamic computed tomography scan showed a high-density tumor in the early phase. After embolization of the right branch of the portal vein, resection of the right lobe of the liver and the extrahepatic bile duct was performed. A resected specimen showed a white-colored mass 8 mm in diameter at the origin of the anterior segmental biliary branch. In the pathological findings, the diagnosis was a poorly differentiated hepatocellular carcinoma with strong nuclear atypia; the tumor filled the bile duct, forming a trabecular structure. The immunohistological stains of the tumor were positive for cytokeratin (CK) 8, CK18, and HepParl and negative for alpha-fetoprotein, carcinoembryonic antigen, CA19-9, CK7, CK19, and CK20. There was atypia in the biliary lining epithelium adjacent to the tumor, and the hepatocellular carcinoma may have developed from the biliary epithelium.

Background/purpose: This study investigated vascular endothelial growth factor (VEGF) and flk-1 expression in hepatic metastases from colon carcinoma, and their associations with tumor angiogenesis, proliferation, and apoptosis.

Methods: Immunohistochemical studies were performed for VEGF/flk-1, Ki-67, p53, and bcl-2 expression, and microvessel density (MVD) in surgical specimens from 35 patients who underwent hepatectomy for colon cancer liver metastases between 1986 and 2001.

Results: VEGF and flk-1 were expressed mainly in the cytoplasm of tumor cells. High VEGF expression was associated with high flk-1 expression (P = 0.043). MVDs of less than 15 and 15 or more were found in 5 (14.3%) and 30 (85.7%) of 35 hepatic metastases, respectively. A Ki-67 index (KI) of 50% or more was detected in 33/35 (94.3%) of tumors, and 23 of these (65.7%) showed a KI of 85% or more. A KI of less than 50% was present in 2/35 (5.7%) of tumors. The expression of VEGF/flk-1 was related to elevated MVD (P < or = 0.026). VEGF was also associated with an increased KI (P = 0.025). Mutant p53 and bcl-2 expressions were detected in 26/35 (74.3%) and 17/35 (48.6%) of liver metastases, respectively. Mutant p53 was not related to VEGF/flk-1 expression, but bcl-2 was highly associated with flk-1 (P = 0.007). The incidences of high flk-1 expression and a KI of 85% or more were significantly higher in tumors which were both p53- and bcl-2-positive (93.3% and 73.3%) than in tumors which were negative for both (42.9% and 14.3%; P < or = 0.021).

Conclusions: The VEGF-flk-1 system takes part in tumor angiogenesis, proliferation, and apoptosis in colon liver metastases. The bcl-2 pathway may upregulate VEGF activity via the flk-1 receptor. These findings are preliminary, requiring a larger sampling in order to elucidate the role of VEGF/flk-1 in metastatic colon cancer.

Although it is quite small, the papilla of Vater is an important part of the body. Carcinoma of the papilla may be one of the smallest cancers that can cause death. The 5-year survival rate after resection was 51%, which is not satisfactory. In this article, the topics discussed are (1) pathogenesis, (2) histological characteristics, and (3) the molecular biological characteristics of carcinoma of the papilla of Vater. From results obtained by the investigation of 576 autopsied and 51 resected cases, atypical epithelium was found most frequently in the common channel, where pancreatic juice and bile mix physiologically. Atypical epithelia may be a precursor of carcinoma of the papilla of Vater. Carcinoma of the papilla of Vater could be classified into two types histologically, an intestinal type and a pancreaticobiliary type. The prognosis of patients with the intestinal type was much better than that of patients with the pancreaticobiliary type. These two types of carcinoma should be treated by different operative procedures or adjuvant therapies. Regarding the molecular biological characteristics of carcinoma of the papilla of Vater; (1) K- ras mutation is mainly associated with the intestinal type, and carcinomas of the intestinal and pancreaticobiliary types may develop via different mechanisms; (2) p53 overexpression may play a role in tumor ulceration; and (3) p21/Waf1 overexpression was significantly correlated with a poor prognosis.

We report a case of pancreatic injury, caused by a stab wound, in which ductal injury and wound depth were clearly identified by intraoperative ultrasonography. A 65-year-old woman was emergently admitted to our hospital after stabbing herself in the abdomen in a suicide attempt. Preoperative computed tomography (CT) and laboratory examination revealed liver and pancreatic injury with massive abdominal bleeding and free air. Operative findings included injuries of the stomach, small bowel, colon, liver, and pancreas. The pancreatic lacerations were 1 cm in length, in the body. Intraoperative ultrasonography enabled the diagnosis of a lacerated main pancreatic duct with no damage to the major vessels posterior to the pancreas. Distal pancreatectomy; simple repairs of the liver, small bowel, and stomach; exteriorization of the injured colon; cholecystostomy; gastrostomy; and jejunostomy were performed. The patient recovered and was transferred to a psychiatric hospital 87 days after surgery. In this patient, intraoperative ultrasonography was successfully used to identify the degree of injury to the pancreatic duct, as well as the depth of the stab wound. In conclusion, intraoperative ultrasonography should be routinely performed to detect main pancreatic duct injury in penetrating pancreatic trauma.

The purpose of this review is to address three important questions concerning hepatic resection for multiple colorectal metastases. (1) Is the number of tumors truly a significant prognostic factor? (2) Are patients with four or more tumors contraindicated for hepatic resection? (3) Up to how many nodules should we attempt to resect? Although the efficacy of surgical resection for one to three hepatic metastases is clear, based on several reports, the literature regarding the resection of four or more metastatic lesions is conflicting. Review of the data at our institutions showed that the number of tumors was a significant prognostic factor, because patient survival after liver resection for multiple metastases was worse than that for single metastasis. However, patients with two or three nodules and those with four or more nodules showed the same survival curves, or those with four or more metastases fared even better. Therefore, patients with four or more metastases should be considered for hepatic resection. The maximum number of hepatic tumors in longterm survivors reported in the literature has been increasing, and the limit for the number of respectable metastases has not yet been determined. Because liver resection is still the only treatment that offers a cure, surgery for multiple metastases may be justified as long as the operation is safe and technically feasible.

Arterial stimulation and venous sampling was effective in the localization of Beta-cell hyperplasia of the pancreas in the islets of Langerhans in an 84-year-old woman. The patient presented with repeated episodes of unconsciousness and hypoglycemia. She was first suspected of having insulinoma, but diagnostic imaging failed to reveal any tumors. Arterial stimulation and venous sampling (ASVS) and percutaneous transhepatic portal venous sampling (PTPS) were performed to localize the tumor. By ASVS, increases in immuno reactive insulin (IRI) were noted in renal vein blood samples (because a splenorenal shunt was present) after splenic arterial stimulation and venous sampling, and PTPS revealed a stepup in IRI from splenic venous blood samples. Preoperative diagnosis suggested Beta-cell hyperplasia in the pancreas tail. Intraoperative ultrasound failed to find a tumor. Intraoperative ASVS showed the site of increase IRI as the pancreas tail, so distal pancreatectomy and splenectomy were performed. However, hypoglycemia was observed constantly after this operation. Relaparotomy, causing additional resection, was conducted to confirm the precise location and to remove the residual Beta-cell hyperplasia of the pancreas. At the second resection, the existing part of Beta-cell hyperplasia was confirmed through intraoperative ASVS, and additional resection of the pancreas body and neck was performed. At this time, complete removal of the residual Beta-cell hyperplasia was confirmed through ASVS. The hypoglycemia and impaired consciousness disappeared after the operation, and the patient's blood sugar level was maintained at a normal level. Pathological findings revealed islets of Langerhans hyperplasia extending to 1 cm in the pancreas tail region. We conclude that pre- and intraoperative ASVS is a useful test for Beta-cell hyperplasia, which is difficult to diagnose through ordinary imaging techniques.

Orthotopic liver transplantation (OLT) is usually associated with significant blood loss and frequently requires the usage of blood products. OLT has been offered sparingly in Jehovah's Witness (JW) patients because of their refusal to accept blood products for religious reasons. Several innovations have made surgery safer in these patients. These include the pre-operative use of erythropoietin to increase red cell mass, the use of intraoperative cell salvage and acute normovolemic hemodilution, and judicious postoperative blood testing. Thoughtful perioperative decision-making and careful surgical techniques remain the cornerstone to a successful outcome. We report our experience in a two-stage hepatectomy done for a JW patient who underwent live donor liver transplant from his mother, also a JW, without blood transfusion. The recipient had an unusually enlarged left lateral segment of the liver which was densely adherent to the spleen. Removing these adhesions in the presence of significant portal hypertension would have resulted in considerable blood loss. This was successfully avoided by leaving this portion of the liver attached to the spleen while proceeding with the hepatectomy. The right lobe of the liver from the donor was then implanted uneventfully. Two weeks later the remaining segment of the recipient liver was removed without incident. The two-stage procedure was life-saving in this JW patient.