Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

A Japanese Boy With Spotted Fever and Overlapping Symptoms of Kawasaki Disease: A Case Report

Japanese spotted fever (JSF) is a tick-transmitted infection caused by Rickettsia japonica (R. japonica), which is indigenous to Japan. Patients with JSF typically present with fever and spotted erythema on the palms and/or soles, and most of them have site(s) of tick bites. The prognosis is good, but some cases have a fatal course. Kawasaki disease (KD) is a systemic vasculitis with an unknown cause that is characterized by symptoms such as fever, conjunctival injection, oral findings, amorphous rash, rigid edema, and nonsuppurative cervical lymphadenopathy. Although the symptoms of JSF are partially similar to those of KD, case reports of JSF overlapping KD have never been internationally published. Herein, we report a boy with JSF and KD symptoms. A five-year-old boy presented with fever and rash after he had been on a mountain inhabited by R. japonica. On the fifth day, erythema was spotted mainly on his bilateral palms, bilateral cervical lymphadenopathy, rigid edema of his lower feet, and mild conjunctival injection appeared. Intravenous immunoglobulin (IVIG) therapy was performed because these symptoms satisfied five out of the six diagnostic criteria for KD. However, on the sixth day, the fever persisted, and then we readministered IVIG in addition to tosufloxacin and azithromycin since we found a tick-bite eschar, which suggested a complication of JSF. His symptoms resolved soon after this treatment. Coronary artery lesions were never observed. This case indicates that the R. japonica infection overlaps clinically with KD. Tosufloxacin and azithromycin should be considered to avoid the use of minocycline in younger patients with JSF.

Congenital Echovirus 11 Infection in a Neonate

Neonates infected with enterovirus in utero would be fulminant at birth or develop symptoms within a few days. Echovirus 11 causes life-threatening hepatic necrosis with coagulopathy and adrenal hemorrhagic necrosis. The prognosis depends on the enterovirus serotype and the absence of serotype-specific maternal antibodies at the time of delivery. We describe a fatal neonatal case of congenital echovirus 11 infection.

Effects of non-technical skill-based surgical education for trainees on herniorrhaphy outcomes

INTRODUCTION

Non-technical skills are essential for surgical patient safety and are implemented in clinical practice. However, training for non-technical skills has not been thoroughly investigated. This study aimed to evaluate the learning curve for non-technical skill-based education in herniorrhaphy.

METHODS

Quality improvement initiatives, including non-technical skill-based intervention, were performed in the department of surgery. The intervention included declaring the patient safety policy, briefing and debriefing, and criterion for the switching of places of the trainee and instructor as defined by the department. Patients who underwent herniorrhaphy from April 2014 to September 2017 were included.

RESULTS

A total of 14 trainees and nine instructors in the pre-intervention period and 14 trainees and seven instructors in the intervention period were included in this study. The median experience of each trainee was 28 and 15 cases in the pre-intervention and intervention groups, respectively. A total of 749 patients were included: 473 in the pre-intervention period and 328 in the intervention period. Demographics and hernia types were mostly similar between groups, and morbidity was not statistically different between the two groups (3.4 vs. 1.2%, p = 0.054). The nonlinear regression model showed an early decline and deep plateau phase of the learning curve in the intervention group. A significant difference was observed in the plateau operation time (61 min in the pre-intervention group and 52 min in the intervention group).

CONCLUSION

This study demonstrated the effectiveness of non-technical skill-based intervention for surgical training. An early decline and deep plateau of the learning curve can be achieved with well-implemented quality improvement initiatives. Nonetheless, further studies are needed to establish a training program for non-technical skill-based learning.

[A Case of Local Recurrent Liver Metastasis from Sigmoid Colon Cancer after Complete Histological Remission, Treated with Rehepatectomy]

We report a case of a patient with sigmoid colon cancer and multiple liver metastases who underwent hepatectomy after chemotherapy and pathological results showed complete remission. However, after chemotherapy was discontinued, the patient developed a local recurrence of the liver metastasis and underwent rehepatectomy. The patient came to our hospital with lower abdominal pain. Colonoscopy revealed a circumferential type Ⅱ, well-differentiated adenocarcinoma. Laparoscopic sigmoidectomy with lymph node dissection was performed. Postoperative CT scan showed multiple liver metastases at S5, S7, and S8. 11 cycles of bevacizumab plus modified FOLFOX(mFOLFOX)were subsequently performed. The liver metastases shrank at all sites, and the patient underwent right hepatectomy. The resected specimen was considered to be in complete remission, with no evidence of viable malignant cells. Postoperatively, bevacizumab plus mFOLFOX was resumed for 6 cycles and the patient remained in remission. However, 3 months after stopping chemotherapy and 1 year and 6 months after hepatectomy, a follow-up CT scan showed local recurrence of the liver edge, and a diagnosis of local recurrence of liver metastasis was made, and a partial hepatectomy was performed. The patient is recurrence-free and resuming modified FOLFOX 9 months after surgery.

[A Case of Locally Advanced, Unresectable Pancreatic Cancer with Superior Mesenteric Artery Invasion Treated with FOLFIRINOX plus Radiation Therapy, followed by Conversion Surgery]

We report a case of a woman in her 70s who underwent conversion surgery after FOLFIRINOX, followed by radiation therapy for initially locally advanced unresectable pancreatic cancer. She visited her local doctor with a chief complaint of upper abdominal pain. Contrast-enhanced CT scan of the abdomen revealed an irregular mass invading the superior mesenteric artery, and the first and second jejunal arteries(>180°)in the pancreatic uncinate region. Based on imaging, she was diagnosed as UR-LA(sm), cT4N0M0, cStage Ⅲ pancreatic cancer, and underwent 5 courses of modified FOLFIRINOX. Radiation therapy of 50.4 Gy was added for local control, and CA19-9 decreased from 394.1 U/mL to 10.5 U/mL. The treatment effect was judged as RECIST: partial response. The tumor was considered to be potentially curative, and a subtotal stomach preserving pancreaticoduodenectomy was performed 8 months after the initial treatment. The tumor was found to be 3× 2 mm in size, pStage ⅠA, R0, and the response to preoperative chemotherapy: Evans Grade Ⅲ. The patient is alive at 5 months postoperatively without recurrence.

[Lymph Node Dissection and Postoperative Follow-Up for T2 Cancer of the Lower Rectum]

The outcomes of 88 patients with lower rectal T2 cancer who underwent radical A surgery(T2)were compared with those of 340 patients with T3 or T4a cancer(T3/T4a)and 51 patients with T1 cancer(T1). The rates of all lymph node(LN) metastasis, paraintestinal LN metastasis, intermediate and main LN metastasis, and lateral LN metastasis in T2 were all significantly lower than in T3/T4a and not different from those in T1. The recurrence rate of T2 was 15.9%, significantly lower than that of T3/T4a and not different from that of T1. Fifty percent of T2 recurrences were observed after 30 months postoperatively, significantly higher than that of T3/T4a and not different from that of T1. The 5-year survival rate of T2 was significantly higher than that of T3/T4a and did not differ from that of T1. In lower rectal T2, cancer LN dissection similar to that in T1 is appropriate, and high preoperative serum CA19-9 level is a risk factor for recurrence, suggesting the need for follow-up after 30 months postoperatively to take recurrence into consideration.

[Resection of Multiple Metastases after Liver Resection from Colon Cancer-A Case Report]

A 49-year-old female was underwent laparoscopic right hemicolectomy for ascending colon cancer and liver metastasis. Then, she was underwent laparoscopic hepatectomy. She received BEV plus mFOLFOX6 therapy as postoperative adjuvant chemotherapy, but she had liver recurrence. She received FOLFOXIRI therapy. Although tumor tended to progressive, it was localized, so laparoscopic hepatectomy was performed again. She received AFL plus FOLFIRI therapy. Fourteen months after hepatic resection, disseminated nodules and lung metastases were found. However, both of peritoneal dissemination, and lung metastasis were localized, so it was judged that peritoneal dissemination and lung metastasis could be resectable. Then, peritoneal dissemination resection and sigmoid colectomy were performed, and then lung resection was performed to perform R0 resection. R0 resection and multimodal therapy for simultaneous and heterotopic metastases of colorectal cancer can contribute to provide a long-term prognosis.

Change in the Number of Patient Safety Reports Through a 16-Year Patient Safety Initiative: A Retrospective Study Focusing on the Incident Severity and Type in a Japanese Hospital

Purpose

To describe the long-term quantitative change in the number of submissions of patient safety reports after the introduction of a patient safety reporting system, focusing on incident severity and type.

Patients and Methods

This study was performed at a tertiary care hospital in Japan. Patient safety reports from 2006 to 2020 were retrospectively reviewed. Incident severity was classified from level 0 (near miss) to level 5 (fatality). The incident types included those related to medication, patient care, drains and catheters, procedures and interventions, examinations, medical devices, and blood transfusions. The study period was divided into 1. 2004–2007; 2. 2008–2014; and 3. 2015–2020 based on the implementation of hospital patient safety strategies. The number of reports per hospital worker was compared among the study periods and the incident levels and types.

Results

We analyzed 96,332 reports extracted from the patient safety reporting system of the hospital. The total number of reports per hospital worker has increased over time. The numbers of levels 0 and 1 incidents increased throughout the study period. In addition, levels 3a and 3b incidents increased between periods 2 and 3. All incident types, except for procedure and intervention-related incidents, increased between periods 1 and 2 and between periods 1 and 3. The number of procedure and intervention-related incidents increased between periods 2 and 3, although it did not between periods 1 and 2.

Conclusion

We found increases in the number of patient safety reports according to the incident severity and type. This suggests two contextual changes occurring during the cultural maturity process, which reflected the development of organizational patient safety culture in our institution. The first was the establishment of a reporting attitude in the institution. The second was to overcome barriers to patient safety.

A case of Vp4 hepatocellular carcinoma with tumor thrombosis extending into the confluence of the splenic/portal vein achieved a good prognosis with emergent hepatectomy and postoperative adjuvant therapy with lenvatinib

In this report, we describe a case of highly advanced hepatocellular carcinoma with tumor thrombosis extending into the main portal vein of the pancreas that was successfully treated with adjuvant lenvatinib after right hepatic resection with thrombectomy. A 70-year-old woman was referred from the clinic because of elevated hepatobiliary enzymes. The patient was positive for the hepatitis B virus antigen at our hospital. The tumor markers were highly elevated with alpha-fetoprotein (14.5 U/mL) and protein induced by vitamin K absence (PIVKAII) (1545 ng/mL), suggesting hepatocellular carcinoma. Dynamic abdominal computed tomography showed an early enhanced tumor approximately 6 cm in size and portal vein tumor thrombosis filling the main portal vein, but not extending into the splenic or superior mesenteric vein (SMV). On magnetic resonance imaging 1 week after CT, portal vein tumor thrombosis had extended to the confluence of the splenic vein with the SMV, indicating rapid tumor growth. Thus, we performed emergent right hepatectomy with tumor thrombectomy. Postoperatively, we treated the patient with lenvatinib for a tumor reduction surgery. Fortunately, the patient was alive 2 years postoperatively without recurrence. This case report suggests that a favorable outcome may be achieved with multidisciplinary treatment including resection and postoperative treatment with lenvatinib.

Natural history of intracholecystic papillary neoplasm (ICPN): a rare case of ICPN whose natural history was closely followed by ultrasound

The natural history of intracholecystic papillary neoplasm (ICPN), especially the speed of growth from small benign to a carcinomatous lesion, is quite unrevealed. Here, we report an extremely rare case of ICPN, in which the papillary lesion was observed transforming from small and benign to malignant using abdominal ultrasound (AUS) over 2 years during routine health checks. A 44-year-old man underwent a routine health check-up. The initial AUS showed a small sessile polyp in the gallbladder, which enlarged slightly at the next AUS, a year later. In the third year, the polypoid lesion enlarged markedly, with a maximum diameter of 10 × 9 × 7 mm. Therefore, a laparoscopic cholecystectomy was performed. Microscopically, the 10 mm tumor had intracytoplasmic mucus, and a clear cytoplasm compatible with gastric-type features. Immunohistochemical analysis showed positive staining of atypical cells for MUC6 and PAS. These findings led to the diagnosis of ICPN with high-grade intraepithelial neoplasia of the gastric type. In conclusion, sessile polyps with rapid growth might be a crucial finding in the early stage of ICPN.

Significant positive impact of duodenum-preserving pancreatic head resection on the prevention of postoperative nonalcoholic fatty liver disease and acute cholangitis

AIM

This study aimed to compare the incidence of postoperative nonalcoholic fatty liver disease (NAFLD), postoperative cholangitis, and fibrosis-4 (FIB)-4 index in patients who underwent duodenum-preserving pancreatic head resection (DPPHR) and pancreaticoduodenectomy (PD) for low-grade malignant tumors and verify the usefulness of DPPHR in preventing the occurrence of these disorders.

METHODS

This retrospective study included 70 patients who underwent PD (n = 39) and DPPHR (n = 31) between 2006 and 2018 for benign or low-grade malignant tumors. The present study compared the preoperative background, cumulative incidence of postoperative NAFLD and cholangitis, and other biochemical markers, including the FIB-4 index. Subanalysis by propensity score matching (PSM) analysis was conducted to minimize treatment selection bias.

RESULTS

In terms of the cumulative incidence of NAFLD, the 5-y incidence was significantly lower in the DPPHR group than in the PD group both before (10% vs 38%, P = .002) and after (13% vs 38%, P = .008) matching. Multivariate analyses identified DPPHR as the only independent preventive factor for postoperative NAFLD (hazard ratio: 0.160, 95% confidence intervals: 0.034-0.76, P = .021). The 5-y cumulative incidence of postoperative cholangitis was significantly higher in the PD group than in the DPPHR group before (51% vs 3%, P < .001) and after (49% vs 4%, P < .001) matching. The FIB-4 index at 12 mo postoperatively was significantly better in the DPPHR group than in the PD group (1.45 vs 2.35, P = .006) before matching.

CONCLUSION

Preservation of the duodenum and bile duct may contribute to preventing long-term postoperative NAFLD and cholangitis, and liver fibrosis for benign or low-grade malignant pancreatic head tumors.

Two cases of pancreatic colloid carcinoma with different pathogenesis: case report and review of the literature

The two patterns of pathogenesis for pancreatic colloid carcinoma are reported; (1) progression from ordinary ductal adenocarcinoma, a subtype of invasive pancreatic ductal carcinoma, and (2) progression from papillary adenocarcinoma derived from intraductal papillary mucinous neoplasm (IPMN) or mucinous cystic neoplasm (MCN). Whether these two conditions are the same disease remains controversial. Case Report 1. An 81-year-old woman was evaluated for an increased carbohydrate antigen 19-9 (CA19-9) value (130 U/mL) detected at 4-year follow-up after distal pancreatectomy for IPMN. Based on the image findings, a local recurrence of IPMN was diagnosed, and the patient underwent a remnant total pancreatectomy. Histopathologic findings showed marked mucus production from the tumor, also noteworthy because mucous nodule formation occurs in more than 80% of tumor. Fibrosis around the mucous cavity was noted, and a low papillary lesion was found in part of the cyst wall, which was contiguous to a flat, basal area; its nucleus was enlarged and heterogeneous in size, which is considered to be a component of intraductal papillary mucinous (IPMC). Therefore, the patient was diagnosed with pancreatic colloid carcinoma derived from IPMN. Case report 2 a 71-year-old man was evaluated for jaundice. Based on the image findings, a diagnosis of pancreatic head cancer was made, and a substomach preserving pancreaticoduodenectomy was performed. Histologically, marked mucus production and floating cuboidal masses of atypical cells without mucinous nodules were seen. Mucinous nodule formation is observed in more than 80% of tumor, but there was no IPMN component, which led to the diagnosis of pancreatic colloid carcinoma. In conclusion, there might be two types of colloid carcinoma of the pancreas, and further study is needed to determine whether these diseases are truly the same or not.

[Efficacy of Hepatic Artery Resection without Reconstruction in Pancreaticoduodenectomy, Paying Attention to the Anomaly of the Artery]

In performing PD, it is very important to understand the running and anatomy of the hepatic artery and the positional relation with the tumor before surgery, leading to planning a proper surgical procedure. In this case series, we report 2 cases in which radical resection was achieved by pancreaticoduodenectomy(PD)with combined hepatic artery resection(without reconstruction)while paying attention to the positional relationship between the bifurcated hepatic artery and the tumor in the head of the pancreas. Case 1: A 73-year-old man. He visited the hospital with jaundice and was diagnosed with distal bile duct cancer. Preoperative contrast-enhanced CT showed that the replaced right hepatic artery(RRHA)was involved by the tumor. Intraoperatively, it was confirmed by ultrasonography that the arterial blood flow in the right lobe of the liver was flowing from the left hepatic artery through the hepatic hilar plate after clamping the right hepatic artery. Thus, PD with combined RRHA resection(without reconstruction)was performed. After the operation, there was no problem with hepatic artery blood flow, and R0 resection was achieved. Case 2: A 65-year-old man. He visited the hospital with jaundice as the chief complaint and was diagnosed with pancreatic head cancer with encasement in the proper hepatic artery(PHA). In this case, the right hepatic artery branches from the SMA and the left hepatic artery branches from the left gastric artery. Intraoperative findings showed no problem with hepatic artery blood flow even after test-clamping the common hepatic artery, and the common hepatic artery was not reconstructed. There is no postoperative complication, and R0 resection was achieved pathologically. Conclusion: For pancreatic head tumors with hepatic artery infiltration, it is important to understand the anatomy of hepatic artery preoperatively and to confirm the intraoperative blood flow. In such cases, pancreaticoduodenectomy with hepatic artery resection may contribute to achieving R0.

[A Case of Resection of Pancreatic Body Cancer Successfully Treated with GEM plus Nab-PTX]

The case was a 72-year-old man who had been on medication due to chronic pancreatitis since 2009 and was referred to our hospital because dilation of the main pancreatic duct was shown by abdominal ultrasonography. The contrast CT scan of the abdomen showed a 30 mm in size, poorly enhanced tumor at the body of the pancreas, which was suspected to invasion the celiac artery, common hepatic artery, and splenic artery. EUS showed a hypoechoic tumor with a diameter of 29× 24 mm. ERCP showed disruption of the pancreatic duct in the body of the pancreas, and cytological examination of the pancreatic juice showed a suspicious positive result. We diagnosed unresectable locally advanced pancreatic cancer in the body of the pancreas and underwent chemotherapy(gemcitabine plus nab-paclitaxel: GnP). Contrast-enhanced CT after 6 courses of GnP showed tumor shrinkage. FDG-PET/CT revealed a slightly in fluorine-18-deoxyglucose(FDG)accumulation in the tumor, but no accumulation around the blood vessels. Based on the above, it was judged that the tumor was possible radical resection, and surgery was performed. Intraoperative frozen section examination revealed no malignant findings in the tissues surrounding the main artery near the pancreatic body cancer, and distal pancreatectomy was performed. Histopathologically, the tumor showed findings of tubular adenocarcinoma, and the histological response to neoadjuvant therapy was Grade 2. We report a case in which conversion surgery was possible by chemotherapy.

Laryngeal web with 22q11.2 deletion syndrome

Laryngeal web is a rare congenital or acquired disease that results in airway stenosis. Depending on the severity of atresia, patients with laryngeal web show a wide variety of symptoms ranging from asymptomatic to life-threatening respiratory dysfunction that may require emergency tracheostomy immediately after birth. We report a neonatal case of laryngeal web with 22q11.2 deletion syndrome. Post-delivery, the infant showed dysphonia and had a ventricular septal defect with characteristic craniofacial features. The infant underwent an endoscopic incision of the web and cardiac surgery. Among patients with laryngeal web, 30% have 22q11.2 deletion syndrome. 22q11.2 deletion syndrome is the most common chromosomal microdeletion syndrome and the second most common chromosomal abnormality associated with congenital heart disease. Therefore, if an infant has laryngeal web with comorbidities such as congenital heart disease, 22q11.2 deletion syndrome should be considered in differential diagnosis.

The usefulness of preoperative exocrine function evaluated by the 13C-trioctanoin breath test as a significant physiological predictor of pancreatic fistula after pancreaticoduodenectomy

Background

The association between pancreatic fistula (PF) after pancreaticoduodenectomy (PD) and preoperative exocrine function is yet to be elucidated. This study aimed to evaluate the association between the preoperative results of the ¹³C-trioctanoin breath test and the occurrence of PF, showing the clinical relevance of the breath test in predicting PF.

Method

A total of 80 patients who underwent ¹³C-trioctanoin breath tests prior to PD from 2006 to 2018 were included in this study. Univariate and multivariate analyses were conducted to reveal the preoperative predictors of PF, showing the association between ¹³C-trioctanoin absorption and PF incidence.

Results

Among 80 patients (age, 68.0 ± 11.9 years, 46 males and 34 females; 30 pancreatic ductal adenocarcinoma [PDAC]/50 non-PDAC patients), the incidence of PF was 12.5% (10/80). Logistic regression analysis results revealed that the frequency of PF increased significantly as the ¹³C-trioctanoin breath test value (Aa% dose/h) increased (odd’s ratio: 1.082, 95% confidence interval: 1.007–1.162, p = 0.032). Moreover, the optimal cutoff value of the preoperative fat absorption level to predict PF was 38.0 (sensitivity, 90%; specificity, 74%; area under the curve, 0.78; p = 0.005). Indeed, the incidence of PF was extremely higher in patients whose breath test value was greater than 38.0 (33%, 9/27) compared with that in patients with values less than 38.0 (1.8%, 1/53).

Conclusions

Favorable preoperative fat absorption evaluated using the ¹³C-trioctanoin breath test is a feasible and objective predictor of PF after PD.

Right hepatectomy with preservation of the entire caudate lobe in patients with metastatic liver tumors: a case of a new hepatectomy technique and treatment strategy for patients with marginal liver function

Background

Performing major hepatectomy for patients with marginal hepatic function is challenging. In some cases, the procedure is contraindicated owing to the threat of postoperative liver failure. In this case report, we present the first case of marginal liver function (indocyanine green clearance retention rate at 15 min [ICGR15]: 28%) successfully treated with right hepatectomy, resulting in total caudate lobe preservation.

Case presentation

A 71-year-old man was diagnosed with sigmoid colon cancer with three liver metastases (S5, S7, and S8). All of metastatic lesions shrunk after chemotherapy, but his ICGR15 and indocyanine green clearance rate (ICGK) were 21% and 0.12, respectively. Moreover, the remnant liver volume was only 39%. Therefore, portal venous embolism (PVE) of the right portal vein was suggested. Portography showed divergence of the considerably preserved right caudate lobe branch (PV1R) from the root of the right portal vein. The liver function was reevaluated 18 days after PVE was suggested. During this time, the ICGR15 (21–28%) and ICGK rate (0.12–0.10) deteriorated. The right caudate lobe was significantly enlarged; thus, a total caudate lobe-preserving hepatectomy (TCPRx) was performed. Patients eligible for TCPRx included those with (1) hepatocellular carcinoma or metastatic liver cancer, (2) no tumor in the caudate lobe, (3) marginal liver function (ICG Krem greater than 0.05 if TCPRx was adapted; otherwise, less than 0.05) and Child–Pugh classification category A, and (4) preserved PV1R and right caudate bile duct branch. The procedure was performed through (A) precise estimation of the remnant liver volume preoperatively, (B) repeated intraoperative cholangiography to confirm the biliary branch of the right caudate lobe (B1R) conservation, and (C) stapler division of posterior and anterior Glisson’s pedicles laterally to avoid injuries to the PV1R and B1R.

Conclusions

Right hepatectomy with total caudate lobe preservation, following PVE, was a safe and viable surgical technique for patients with marginal liver function.

Combining Failure Modes and Effects Analysis and Cause-Effect Analysis: A Novel Method of Risk Analysis to Reduce Anaphylaxis Due to Contrast Media

BACKGROUND

Contrast media agents are essential for computed tomography-based diagnoses. However, they can cause fatal adverse effects such as anaphylaxis in patients. Although it is rare, the chances of anaphylaxis increase with the number of examinations. Thus, we aimed to design a quality-improvement initiative to reduce patient risk to these agents.

METHODS

We analysed computed tomography processes using contrast iodine in a tertiary-care academic hospital that performs approximately 14,000 computed tomography scans per year in Japan. We applied a combination of failure modes and effects analysis and cause-effect analysis to reduce the risk of patients developing allergic reactions to iodine-based contrast agents during computed tomography imaging.

RESULTS

Our multidisciplinary team comprising seven professionals analysed the data and designed a 56-process flowchart of computed tomography imaging with iodine. We obtained 177 failure modes, of which 15 had a risk-probability number higher than 100. We identified the two riskiest processes and developed cause-and-effect diagrams for both: one was related to exchange of information between the radiation and hospital information system regarding the patient's allergy, the other was due to education and structural deficiencies in observation following the exam.

CONCLUSION

The combined method of failure mode effect analysis and cause-and-effect analysis reveals high-risk processes and suggests measures to reduce these risks. Failure modes and effects analysis is not well-known in healthcare but has significant potential for improving patient safety. Our findings emphasise the importance of adopting new techniques to reduce patient risk and carry out best practices in radiology.

[Cooperative Surgery with Gastroenterological Surgeons in Gynecologic Malignant Tumors]

Secondary debulking surgery(SDF)for gynecologic malignancies may improve prognosis. However, recurrent lesions may be invasions of the intestinal tract and observed peritoneal dissemination. SDF can be safely carried out by performing cooperative surgery with a gastroenterological surgeon and gynecologists. Precise cooperation is indispensable for the operation, especially when it comes to aspects such as the contact method and perioperative management at that time. In our hospital, if the gynecologist suspects other organs invasion during a preoperative examination, they contact the gastroenterological surgeon in an elective manner. If other organs invasion is not clear during a preoperative examination or bowel injury occurs during surgery, the gastroenterological surgeon would be contacted urgently. To ensure smooth cooperation, it is necessary to run regular joint conferences. By sharing in planned and combining the expertise of all the department of interest, it is possible to perform highly curative and safe surgery.

A preserved pancreatic exocrine function after pancreatectomy may be a crucial cause of pancreatic fistula: paradoxical results of the 13C-trioctanoin breath test in the perioperative period

PURPOSE

The aim of this study was to elucidate the association between pancreatic fistula (PF) and the sequential changes in the perioperative exocrine function after pancreatectomy.

METHODS

The subjects were 96 patients who underwent a ¹³C-trioctanoin breath test before and 1 month after pancreatectomy, between 2006 and 2018. We retrospectively compared the pre- and postoperative fat absorption levels between patients with PF (PF group; n = 17) and without PF (non-PF group; n = 79) using the breath test.

RESULTS

The preoperative level of ¹³C-trioctanoin absorption (%dose/h) was comparable between the non-PF and PF groups (36.5 vs. 36.9). In the non-PF group, ¹³C-trioctanoin absorption was significantly decreased after surgery in comparison to the preoperative setting (post-operative 28.5; pre-operative 36.5; p < 0.0001), whereas these values were comparable (post-operative 36.9; pre-operative 34.5; p = 0.129) in the PF group. Moreover, postoperative absorption in the PF group was significantly better than that in the non-PF group (34.5 vs. 28.5%, p = 0.0003). The maximum drain amylase level was significantly higher in patients with a ¹³C-trioctanoin absorption level (%dose/h) of ≥ 30 in comparison to patients with levels of < 30 (2502 vs. 398 U/L, p = 0.001).

CONCLUSION

PF did not exacerbate the pancreatic exocrine function in the early postoperative period, and the acceleration or preservation of the exocrine function after surgery may be an important cause of PF.

Subcutaneous abscess caused by Streptococcus pneumoniae serotype 28F in an infant: a case report

Background

Invasive pneumococcal disease (IPD) is defined by the detection of Streptococcus pneumoniae on culture from samples obtained from a normally sterile site. Pneumococcal conjugate vaccines (PCV) have been developed for the prevention of IPD that is caused by highly virulent serotypes. Despite the effective reduction of IPD caused by vaccine serotypes after the introduction of PCV, there has been a rapid increase in the incidence of IPD caused by non-vaccine serotypes, and serotype replacement has become a global issue.

Case presentation

We report a previously healthy 4-month-old girl presenting with a large subcutaneous abscess caused by S. pneumoniae, identified as non-vaccine serotype 28F. The patient had received routine vaccination, including PCV vaccination. After the incision and drainage of the subcutaneous abscess, the patient was treated with antibiotics. She was discharged on Day 7 of hospitalization without any residual sequelae.

Conclusions

Subcutaneous abscess is a common pediatric skin and soft tissue infection, whereas pneumococcal subcutaneous abscesses are quite rare. As the pneumococcal serotype 28F caused a subcutaneous abscess, this serotype possibly has a high virulence. The incidence of IPD caused by non-vaccine serotypes, such as 28F, is expected to increase in the future. The consolidation of international data on pneumococcal serotypes is important for the development of novel PCV.

Bundle interventions including nontechnical skills for surgeons can reduce operative time and improve patient safety

OBJECTIVE

This study aimed to determine if introducing nontechnical skills to surgical trainees during surgical education can reduce the operation time and contribute to patient safety.

DESIGN

Quality improvement initiatives using the KAIZEN as a problem-solving method.

SETTING

Department of surgery in a referral and educational hospital.

PARTICIPANTS

Surgical team and quality management team.

INTERVENTION

The KAIZEN was used as a problem-solving method between 2015 and 2018 to reduce the operation time. First, baseline measurement was performed to understand the current situations in our department. To achieve continuous improvement, periodical feedback of the current status was obtained from all staff. Bundles, including nontechnical skills, were established. Briefing and debriefing were performed by the surgical team.

MAIN OUTCOME MEASURES

Excessively long operation rates with a standard procedure.

RESULTS

We included 1573 operations in this initiative. Excessively long operation rates were reduced in all types of surgeries, from 27.1% to 15.2% for herniorrhaphy (P = 0.005), 58.3-40.0% for gastrectomy (P = 0.03), 50.0-4.1% for total gastrectomy (P = 0.12), 65.6-45.0% for colectomy (P = 0.004), 67.8-43.2% for high anterior resection (P = 0.02) and 69.6-47.9% for low anterior resection (P = 0.03). The adherence to briefing and debriefing were improved, and majority of the surgeons favored the bundle elements.

CONCLUSIONS

The KAIZEN initiative was effective in clinical healthcare settings. In the event of scaling-up this initiative, the educational program for physicians should include project management strategies and leadership skills.

Long-term renal follow up of preterm neonates born before 35 weeks of gestation

BACKGROUND

The hypothesis of the Developmental Origins of Health and Disease states that environmental factors during fetal and infantile life are risk factors for some chronic diseases in adulthood. Few studies, however, have confirmed this hypothesis early in childhood. Therefore, we assessed how premature birth and low-birthweight (LBW) affect the renal function of Japanese children.

METHODS

This retrospective study surveyed 168 patients who were born before 35 weeks of gestation and were cared for at the present neonatal intensive care unit. Follow-up duration was >2 years. Serum creatinine (sCr) and estimated glomerular filtration rate (eGFR) recorded in medical records were reviewed.

RESULTS

The eGFR at 2 years of age was significantly correlated with birthweight and gestational age (P < 0.01). Approximately 10.7% of the children had low eGFR (<90 mL/min/1.73 m² ) without clinical symptoms or abnormal urine examination. These children had high sCr on day 7 after birth (P < 0.01) and delayed recovery of these levels during the first month after birth.

CONCLUSION

Premature gestational age and LBW directly affect renal function in young children. High sCr on day 7 after birth is a risk factor for chronic kidney disease in children. Careful follow up of renal function is therefore required for premature infants and infants with LBW beginning in early childhood to prevent renal dysfunction.

Development and validation of a nomogram predicting postoperative pneumonia after major abdominal surgery

PURPOSE

Postoperative pneumonia (POP) is a common complication that can adversely affect the outcomes after surgery. This study aimed to devise and validate a model for stratifying the probability of POP in patients undergoing abdominal surgery.

METHODS

We included 1050 patients who underwent major abdominal surgery between 2012 and 2013. A nomogram was devised by evaluating the predictive factors for POP.

RESULTS

Of the 1050 patients, 56 (5.3%) developed POP. Multivariable logistic regression analysis revealed that the independent predictive factors for POP were age, male sex, history of cerebrovascular disease, Brinkman Index (BI) ≥ 900, and upper midline incision. A nomogram was devised by employing these five significant predictive factors. The prediction model showed a relatively good discrimination performance, with a concordance index of 0.77.

CONCLUSIONS

A nomogram based on age, male sex, history of cerebrovascular disease, BI ≥ 900, and upper midline incision may be useful for identifying patients with a high probability of developing POP after major abdominal surgery.

Perioperative Factors Predicting Prolonged Postoperative Ileus After Major Abdominal Surgery

BACKGROUND

Prolonged postoperative ileus (PPOI) is among the common complications adversely affecting postoperative outcomes. Predictors of PPOI after major abdominal surgery remain unclear, although various PPOI predictors have been reported in patients undergoing colorectal surgery. This study aimed to devise a model for stratifying the probability of PPOI in patients undergoing abdominal surgery.

METHODS

Between 2012 and 2013, 841 patients underwent major abdominal surgery after excluding patients who underwent less-invasive abdominal surgery, ileus-associated surgery, and emergency surgery. Postoperative managements were generally based on enhanced recovery after surgery (ERAS) program. The definition of PPOI was based on nausea, no oral diet, flatus absence, abdominal distension, and radiographic findings. A nomogram was devised by evaluating predictive factors for PPOI.

RESULTS

Of the 841 patients, 73 (8.8%) developed PPOI. Multivariable logistic regression analysis revealed smoking history (P = 0.025), colorectal surgery (P = 0.004), and an open surgical approach (P = 0.002) to all be independent predictive factors for PPOI. A nomogram was devised by employing these three significant predictive factors. The prediction model showed relatively good discrimination performance, the concordance index of which was 0.71 (95%CI 0.66-0.77). The probability of PPOI in patients with a smoking history who underwent open colorectal surgery was calculated to be 19.6%.

CONCLUSIONS

Colorectal surgery, open abdominal surgery, and smoking history were found to be independent predictive factors for PPOI in patients who underwent major abdominal surgery. A nomogram based on these factors was shown to be useful for identifying patients with a high probability of developing PPOI.

Insufficient Lymph Node Sampling in Patients with Colorectal Cancer Perforation is Associated with an Adverse Oncological Outcome

BACKGROUND

The impact of lymph node (LN) dissection on long-term outcomes for patients with colorectal cancer (CRC) perforation remains unclear. We aim to investigate factors associated with poor prognosis and recurrence in patients with CRC, with special reference to cancer perforation and LN dissection.

METHODS

The subjects comprised 550 patients who underwent colorectal surgery for CRC at Stage II or III (TNM classification) between February 2006 and November 2013. Short- and long-term outcomes of patients with or without CRC perforation were evaluated. We also sought risk factors on poor prognosis, focusing on LN dissection in patients with CRC perforation.

RESULTS

A total of 508 underwent surgery for CRC without perforation (the non-perforation group) and 39 for CRC with perforation (the perforation group). Both overall survival and recurrence-free survival rates were significantly lower in the perforation group than in the non-perforation group (overall survival, P = 0.009; recurrence-free survival, P < 0.001). The relapse rates at the peritoneum (P = 0.002), lung (P = 0.007) and LNs (P = 0.021) were significantly higher in the perforation group than in the non-perforation group. Multivariable Cox proportional hazards model revealed that CRC perforation (hazard ratio [HR] 2.55, 95 % confidential interval [CI] 1.16-4.98, P = 0.022), LN dissection <12 (HR 1.83, 95 % CI 1.07-3.13, P = 0.027), and Stage III (HR 1.79, 95 % CI 1.06-3.08, P = 0.031) were significant and independent risk factors for poor prognosis.

CONCLUSIONS

Conducting <12 LN dissections independently increased the risk of reduction in overall survival for patients with CRC perforation. Thus, radical LN dissections should be performed to improve patients' survival rates, when patients' general and surgical conditions allow.

Liver transection using indocyanine green fluorescence imaging and hepatic vein clamping

BACKGROUND

Three-dimensional (3D) imaging has facilitated liver resection with excision of hepatic veins by estimating the liver volume of portal and hepatic venous territories. However, 3D imaging cannot be used for real-time navigation to determine the liver transection line. This study assessed the value of indocyanine green (ICG) fluorescence imaging with hepatic vein clamping for navigation during liver transection.

METHODS

Consecutive patients who underwent liver resection with excision of major hepatic veins between 2012 and 2013 were evaluated using ICG fluorescence imaging after clamping veins and injecting ICG. Regional fluorescence intensity (FI) values of non-veno-occlusive regions (FI_Non ), veno-occlusive regions (FI_VO ) and ischaemic regions (FI_IS ) were calculated using luminance analysing software.

RESULTS

Of the 21 patients, ten, four and seven underwent limited resection, monosegmentectomy/sectionectomy and hemihepatectomy respectively, with excision of major hepatic veins. Median veno-occlusive liver volume was 80 (range 30-458) ml. Fluorescence imaging visualized veno-occlusive regions as territories with lower FI compared with non-veno-occlusive regions, and ischaemic regions as territories with no fluorescence after intravenous ICG injection. Median FI_IS /FI_Non was lower than median FI_VO /FI_Non (0·22 versus 0·59; P = 0·002). There were no deaths in hospital or within 30 days, and only one major complication.

CONCLUSION

ICG fluorescence imaging with hepatic vein clamping visualized non-veno-occlusive, veno-occlusive and ischaemic regions. This technique may guide liver transection by intraoperative navigation, enhancing the safety and accuracy of liver resection.

Laparoscopic surgery for small-bowel obstruction caused by Meckel’s diverticulum

A 26-year-old woman was referred to our hospital because of abdominal distention and vomiting. Contrast-enhanced computed tomography showed a blind loop of the bowel extending to near the uterus and a fibrotic band connecting the mesentery to the top of the bowel, suggestive of Meckel’s diverticulum (MD) and a mesodiverticular band (MDB). After intestinal decompression, elective laparoscopic surgery was carried out. Using three 5-mm ports, MD was dissected from the surrounding adhesion and MDB was divided intracorporeally. And subsequent Meckel’s diverticulectomy was performed. The presence of heterotopic gastric mucosa was confirmed histologically. The patient had an uneventful postoperative course and was discharged 5 d after the operation. She has remained healthy and symptom-free during 4 years of follow-up. This was considered to be an unusual case of preoperatively diagnosed and laparoscopically treated small-bowel obstruction due to MD in a young adult woman.

The effects of vitamin A compounds on hyaluronic acid released from cultured rabbit corneal epithelial cells and keratocytes

A role of vitamin A in the synthesis of hyaluronic acid by skin cells is well known. Hyaluronic acid is produced by corneal epithelial cells and keratocytes in the eye. We investigated whether rabbit corneal epithelial cells and keratocytes release hyaluronic acid after exposure to vitamin A compounds. Rabbit corneal epithelial cells and keratocytes were inoculated with RCGM2 medium and incubated at 37ºC under 5% CO(2) in air for 24 h. The medium was then replaced with medium containing 0.1, 1, 10, or 100 μM retinoic acid or retinol palmitate (VApal) and incubated for another 48 h. Hyaluronic acid release from both corneal epithelial cells and keratocytes during culture was increased by retinoic acid at the lower concentration of 0.1 μM and 1 μM determined with a sandwich binding protein assay kit. However, it was significantly decreased at the higher concentrations of 10 μM and 100 μM, and the cell count determined with a Neutral Red assay kit was also decreased at these concentrations. On the other hand, hyaluronic acid release from corneal epithelial cells during culture was increased by VApal at the lower concentration of 0.1 μM and 1 μM, but there was no significant difference in the cell count for either corneal epithelial cells or keratocytes in the presence of VApal at any concentration. In conclusion, it is suggested that vitamin A stimulates the release of hyaluronic acid from cultured rabbit corneal epithelial cells and keratocytes.

Efficacy of retinol palmitate eye drops for dry eye in rabbits with lacrimal gland resection

Purpose

We examined the efficacy of retinol palmitate (VApal) for dry eyes using dry eye model rabbits whose lacrimal glands were resected.

Materials and methods

After alkaline injury on keratoconjunctival epithelium, VApal eye drops were administered 6 times a day for 7 days. The efficacy of VApal was also compared with that of 0.1% hyaluronic acid eye drops.

Results

The fluorescein staining and rose bengal scores showed a significant decrease compared with the score in the vehicle group at 7 days (P < 0.05) in the 1000 IU/mL VApal group and at both 3 days (P < 0.05) and 7 days (P < 0.01) in the 1500 IU/mL VApal group. Histological examination revealed recovery of the corneal epithelium, and PAS staining disclosed the recovery of mucin-producing lower palpebral conjunctival goblet cells after 7 days in the 1500 IU/mL VApal group compared with the vehicle group. Results from impression cytology showed a significant increase in density of conjunctival goblet cells compared with that in the vehicle group after 7 days in the 1000 IU/mL VApal group and after 3 and 7 days in the 1500 IU/mL VApal group. There were no significant changes in tear flow in either group. Topical application of VApal at 1500 IU/mL showed greater improvement than 0.1% hyaluronic acid in both fluorescein and rose bengal score and in the density of conjunctival goblet cells.

Conclusion

It is suggested that VApal is effective for the improvement of keratoconjunctival epithelial damage associated with tear abnormalities, such as dry eyes.

Water/supercritical CO2 microemulsions with mixed surfactant systems

Phase behavior was investigated for water/supercritical CO 2 (W/scCO2) microemulsions stabilized with sodium bis(1H,1H,2H,2H-heptadecafluorodecyl)-2-sulfosuccinate (8FS(EO) 2) mixed with various guest surfactants. Only for the mixtures with fluorocarbon-hydrocarbon hybrid anionic surfactants (FC6-HC n), the maximum water-to-surfactant molar ratio (W0(c)) was larger than that estimated from linear interpolation of the W0(c) values for pure 8FS(EO) 2 and pure guest surfactant. Fourier transform infrared (FT-IR) measurement for the microemulsion revealed that the mixing of 8FS(EO) 2 with FC6-HC n can prevent a phase transition from the microemulsion to the liquid crystal even in the presence of excess water. It was also found from the measurement of water/scCO 2 interfacial tension that the area occupied per surfactant molecule was markedly increased by the mixing with FC6-HC n. The loose molecular packing, probably due to a microsegregation of 8FS(EO) 2 and FC6-HC n, is consistent with the enhanced stability of the microemulsion upon surfactant mixing.

Optimum tail length of fluorinated double-tail anionic surfactant for water/supercritical CO2 microemulsion formation

The effect of surfactant tail structure on the stability of a water/supercritical CO2 microemulsion (W/scCO2 muE) was examined for various fluorinated double-tail anionic surfactants of different fluorocarbon chain lengths, F(CF2)n (n = 4, 6, 8, and 10), and oxyethylene spacer lengths, (CH2CH2O)(m/2) (m = 2 and 4). The phase behavior of the water/surfactant/CO2 systems was studied over a wide range of CO2 densities from 0.70 to 0.85 g/cm(3) (temperatures from 35 to 75 degrees C and pressures up to 500 bar) and corrected water-to-surfactant molar ratios (W0c). All of the surfactants yielded a W/scCO2 muE phase, that is, a transparent homogeneous phase with a water content larger than that permitted by the solubility of water in pure CO2. With increasing W0c, a phase transition occurred from the muE phase to a macroemulsion or a lamella-like liquid crystal phase. The maximum W0c value was obtained at a tail length of 12-14 A, indicating the presence of an optimum surfactant tail length for W/scCO2 muE formation.

Surfactant-mixing effects on the interfacial tension and the microemulsion formation in water/supercritical CO2 system

The effects of surfactant mixing on interfacial tension and on microemulsion formation were examined for systems of air/water and water/supercritical CO2 (scCO2) interfaces and for water/scCO2 microemulsions. A fluorinated surfactant, sodium bis(1H,1H,2H,2H-heptadecafluorodecyl)-2-sulfosuccinate (8FS(EO)2), was mixed with the three hydrocarbon surfactants, Pluronic L31, Tergitol TMN-6, and decyltrimethylammonium chloride (DeTAC), at equimolar ratio. For all the cases, the interfacial tension was significantly lowered by the mixing. The positive synergistic effect suggests that the mixed surfactants tend to pack more closely on the interface than the pure constituents. It was found, however, that the microemulsion formation in scCO2 was never facilitated by the mixing, except for the case of TMN-6. This is probably due to the segregation of the surfactants into hydrocarbon-rich and fluorocarbon-rich phases on the microemulsion surface.

WAVE3 functions as a negative regulator of LDOC1

WAVE3 belongs to the Wiskott-Aldrich syndrome protein family that mediates actin reorganization through activation of the Arp2/3 complex. However, the physiological function of WAVE3 is poorly understood. We found that LDOC1-encoded by a gene that is down-regulated in tumor cell lines-binds directly to the verprolin homology domain of WAVE3. Ectopically expressed LDOC1 is localized in the nucleus and induces apoptosis in the cells. This apoptosis is accompanied by an increase in the p53 protein level, but not in p53 transcription, suggesting that LDOC1 inhibits the degradation of p53. Further, the expression of WAVE3 induces the translocation of LDOC1 from the nucleus to the cytoplasm, resulting in the inhibition of LDOC1-induced apoptosis. Thus, it is possible that the LDOC1 function is negatively regulated by WAVE3.

Effect of a wheat amylase inhibitor on canine carbohydrate digestion, gastrointestinal function, and pancreatic growth

BACKGROUND/AIMS

Chronic amylase inhibition might be useful to treat diabetes mellitus and obesity. Duodenal and ileal cannulas were placed in 8 dogs to determine if long-term ingestion of a wheat amylase inhibitor maintained amylase inhibition or affected gastrointestinal or metabolic function or pancreatic growth.

METHODS

Five dogs were fed and 3 were not fed 1.5 g of the inhibitor with meals for 9 weeks. Postprandial and cholecystokinin octapeptide stimulated pancreatic secretion, and fecal balance studies were performed at intervals. After the experiment, the pancreas was analyzed.

RESULTS

Weight loss was similar in both groups. Amylase inhibition persisted throughout the 9 weeks; it declined from 91% to 37% from the first to the sixth postprandial hour. Amylase inhibition decreased plasma glucose levels during the first hour (P < 0.05), increased carbohydrate delivery to the ileum (315 vs. 555 mg/h; P = 0.002), and increased cholecystokinin octapeptide-stimulated amylase secretion. However, amylase inhibition did not significantly change plasma concentrations of insulin, peptide YY or neurotensin, postprandial pancreatic secretion, gastrointestinal transit or pancreatic weight, and protein or DNA content.

CONCLUSIONS

Prandial ingestion of 1.5 g of the inhibitor for 9 weeks reduces postprandial amylase levels enough to delay carbohydrate digestion and absorption and lower plasma glucose levels without altering pancreatic growth. This dose may be effective to treat diabetes mellitus but not obesity.

Protective effect of lactoferrin on caerulein-induced acute pancreatitis in rats

In rats we studied the effects of lactoferrin on experimental acute pancreatitis caused by a single subcutaneous injection of 100 micrograms/kg body weight of caerulein. Lactoferrin isolated from human milk was given intraperitoneally to rats immediately after the injection of caerulein. The injection of 100 mg/kg body weight of lactoferrin significantly reduced the elevation of the serum amylase level and pancreatic wet weight; histological alterations of the pancreas were markedly suppressed. These results suggested that lactoferrin had a protective effect on the biochemical and histological alterations in this model.

Effect of long-term ethanol feeding on the restoration process of acute necrotizing pancreatitis induced in rats

This study was conducted to elucidate the possible influence of long-term peroral administration of alcohol on the repair process of acute necrotizing pancreatitis. Male Wistar rats fed with balanced diet were divided into two groups. The first group had free access to 15% ethanol, and the second group, the control group, has access to water instead. After fifty weeks, acute necrotizing pancreatitis was induced in rats by infusing 0.4% lysolecithin into their pancreatic duct. In the course of pancreatitis, pancreatic enzymes in serum, enzymes and protein in pancreas, and DNA synthesis in pancreas in both groups, changed in the same way. Histologically, interstitial edema, necrosis of parenchyma, infiltration of inflammatory cells, and formation of tubular complex were observed. Most of these histological changes of pancreas in both groups disappeared in twenty days and pancreas was repaired almost completely. These findings suggest that the repair process of acute necrotizing pancreatitis is not affected by preceding long-term intake of alcohol.

[Antineoplastic effect of UFT therapy (uracil-FT-207 combination therapy) on experimental pancreatic cancer transplanted in the pancreas and subcutaneous region]

The pancreatic duct cell adenocarcinoma induced by di-isopropanol nitrosamine could be easily and repeatedly transplanted into the subcutaneous or pancreatic tissues of the homologous animals. We established a tumor bearing animal design in which tumor tissues were transplanted simultaneously into subcutaneous and pancreatic tissues. At the first week after the transplantation, the animals were divided into three groups: In FT group FT-207 was given at a dose of 15 mg/kg/day, in UFT group FT-207 and uracil were given at a dose of 3 mg/kg/day and; 6.7 mg/kg/day (molar ratio; 1:4), respectively and in control group a solvent of FT-207 was given. In all groups the drugs were administrated orally for ten days. The size of tumors transplanted in subcutaneous and pancreatic tissues increased more slowly in FT and UFT groups, as compared with that of control group. The inhibitory effect on tumor growth observed in UFT group was more striking than that in FT group. No major side effects were observed in all groups. At the fourth weeks after subcutaneous and intrapancreatic transplantation, the animals were divided into two groups: In FT group FT-207 was given at a dose of 30 mg/kg and in UFT group FT-207 and uracil were given at a dose of 30 mg/kg and 67.2 mg/kg, respectively. In both groups the drugs were given orally, and at one hour after the administration all the animals were killed to determine 5-FU concentration in various tissues. The 5-FU concentrations of subcutaneous and intrapancreatic transplanted tumor tissues were significantly higher in UFT group than those in FT group. UFT therapy, therefore, seems to be hopeful for the treatment of human pancreatic cancer.