Arteriovenous malformation of small intestine successfully treated by double-balloon enteroscopy and laparoscope-assisted surgery

Arteriovenous malformation (AVM) of the small bowel is a rare disease and can be sometimes difficult to treat due to the diagnostic difficulty. We herein report a case of small intestinal bleeding of AVM successfully treated with double-balloon enteroscopy (DBE) and laparoscope-assisted resection. A 44-year-old man complained of hematochezia and visited the previous doctor. He underwent gastroscopy and colonoscopy, but no bleeding site was detected. However, he rebled 2 days later and became hypotensive. Abdominal computed tomography revealed a hypervascular nodule in the jejunum. He was transferred to our institution for further treatment. DBE was performed and revealed a small pulsatile lesion with a tiny mucosal break. We then injected a marking tattoo. Two days later, he underwent an operation. We were able to easily locate the tattooed lesion laparoscopically and performed jejunal partial resection. His postoperative course was uneventful. DBE enabled a precise diagnosis and minimal invasive surgery.

Portal venous gas accompanied by gallbladder torsion: a case report

Portal venous gas (PVG) generally suggests critically ill conditions such as severe bowel ischemia. We herein report a rare case of gallbladder torsion with PVG. An 88-year-old woman complained of right hypogastric pain. Ultrasonography (US) showed diffuse wall thickening of her gallbladder and mobile echogenic foci moving inside the portal venous branches. Computed tomography showed a thickened wall of the gallbladder with poor enhancement and tiny pockets of air in the portal venous branches (segments 4 and 5). There was no evidence of other visceral ischemia. She was diagnosed with necrotic cholecystitis and immediately underwent an emergency operation. We found a gangrenous gallbladder with 180° clockwise rotation along the longitudinal axis and performed cholecystectomy. We confirmed the disappearance of PVG with US after the operation. Her postoperative course was uneventful. Gallbladder diseases can produce PVG, and US might be a useful diagnostic modality to evaluate changes in PVG.

A laryngeal foreign body resembling cervical emphysema

An 81‐year‐old woman was referred to our hospital with a chief complaint of chest discomfort; CT imaging suggested for cervical emphysema. However, direct observation revealed a grilled liver stuck to the larynx. Carefully taking the patient's history, especially diet, is important to diagnose a laryngeal foreign body correctly.

Heterogeneity of Glucose Metabolism in Esophageal Cancer Measured by Fractal Analysis of Fluorodeoxyglucose Positron Emission Tomography Image: Correlation between Metabolic Heterogeneity and Survival

BACKGROUND

Intratumoral heterogeneity is a well-recognized characteristic feature of cancer. The purpose of this study is to assess the heterogeneity of the intratumoral glucose metabolism using fractal analysis, and evaluate its prognostic value in patients with esophageal squamous cell carcinoma (ESCC).

METHODS

18F-fluorodeoxyglucose positron emission tomography (FDG-PET) studies of 79 patients who received curative surgery were evaluated. FDG-PET images were analyzed using fractal analysis software, where differential box-counting method was employed to calculate the fractal dimension (FD) of the tumor lesion. Maximum standardized uptake value (SUVmax) and FD were compared with overall survival (OS).

RESULTS

The median SUVmax and FD of ESCCs in this cohort were 13.8 and 1.95, respectively. In univariate analysis performed using Cox's proportional hazard model, T stage and FD showed significant associations with OS (p = 0.04, p < 0.0001, respectively), while SUVmax did not (p = 0.1). In Kaplan-Meier analysis, the low FD tumor (<1.95) showed a significant association with favorable OS (p < 0.0001). In wthe multivariate analysis among TNM staging, serum tumor markers, FD, and SUVmax, the FD was identified as the only independent prognostic factor for OS (p = 0.0006; hazards ratio 0.251, 95% CI 0.104-0.562).

CONCLUSION

Metabolic heterogeneity measured by fractal analysis can be a novel imaging biomarker for survival in patients with ESCC.

A case of giant ileal duplication in an adult, successfully treated with laparoscope-assisted surgery

Alimentary tract duplication is a rare congenital malformation but can occur anywhere along the digestive tract. Most patients become symptomatic in early childhood, and only a few cases of adult patients have been reported in the literature. We herein report a unique case of a giant ileal duplication in an adult, which was successfully treated with laparoscope-assisted surgery. A 60-year-old male was admitted because of abdominal pain. Imaging studies revealed a well-defined cystic mass, measuring 15 cm, in the ileocecal region. We diagnosed it as a duplicated ileum and performed laparoscope-assisted surgery. The duplication was successfully resected with attached normal ileum, and there were no major complications in the postoperative course.

Preoperative hepatic CT perfusion as an early predictor for the recurrence of esophageal squamous cell carcinoma: initial clinical results

Reports suggest that hepatic blood flow may have an association with cancer progression. The aim of the present study was to evaluate whether the hepatic blood flow measured by CT perfusion (CTP) may identify patients at high-risk for postoperative recurrence of esophageal squamous cell carcinoma (ESCC). Prior to surgery, hepatic CTP images were obtained using a 320-row area detector CT. The data were analyzed by a commercially available software based on the dual input maximum slope method, and arterial blood flow (AF, ml/min/100 ml tissue), portal blood flow (PF, ml/min/100 ml tissue) and perfusion index [PI (%) = AF/AF + PF × 100] were measured. These parameters were compared with the pathological stage and outcome of the ESCC patients. Forty-five patients with ESCC were eligible for this study. The median follow-up period was 17 months, and recurrences were observed in 9 patients (20%). The preoperative PI values of the 9 patients with recurrence were significantly higher than those of the 36 patients without recurrence (23.9 vs. 15.9, P=0.0022). Patients were categorized into the following two groups; high PI (>20) and low PI (<20). The recurrence-free survival of the low PI group was significantly better than that of the high PI group (P<0.0001). A multivariate analysis showed that a high PI was an independent risk factor for recurrence (odds ratio, 19.1; P=0.0369). Therefore, the preoperative PI of the liver may be a useful imaging biomarker for predicting the recurrence of patients with esophageal cancer.

Severe diffuse duodenitis successfully treated with intravenous tacrolimus after colectomy for ulcerative colitis

We encountered a rare case of severe diffuse duodenitis associated with ulcerative colitis (UC). A 23-year-old man underwent total proctocolectomy with ileal J-pouch anal anastomosis for UC. He suffered from severe abdominal pain, fever and bloody diarrhea for six months after the surgery. Upper double-balloon enteroscopy disclosed severe diffuse duodenitis, of which the findings were endoscopically and histologically similar to those of colonic lesions of UC. Although the administration of prednisolone was ineffective, treatment with intravenous tacrolimus markedly improved the clinical findings. This is the first report of the successful treatment of severe UC-associated diffuse duodenitis with intravenous tacrolimus.

[Evaluation of false-negative lymph nodes diagnosed by fludeoxy glucose-positron emission tomography in cases of metastatic esophageal squamous cell carcinoma]

We have encountered many cases wherein the metastatic nest of esophageal squamous cell carcinoma occupied only a small space in the lymph nodes because of which computed tomography( CT) and fludeoxy glucose( FDG)-positron emission tomography( PET) could not detect the lymph node metastasis satisfactorily. The false-negative lymph nodes that were not detected by FDG-PET before surgery were smaller in diameter, rate of occupation, and area of occupation than the true-positive lymph nodes. The smallest area of the cancer nest in the true-positive group was 7.5 mm2, and therefore, it was reasonable to consider a 5-mm diameter area as the criteria for correct diagnosis by FDG-PET. Most of the false-negative lymph nodes with a large area of carcinoma were attached to the primary tumor; therefore, they could not be precisely identified. The detection of false-negative lymph nodes by FDG-PET was not precise because of increases in the quantity of stroma-like cells in poorly differentiated carcinomas and in fibrosis caused by neoadjuvant therapy in the lymph nodes.

[Neoadjuvant chemotherapy for advanced colorectal cancer]

BACKGROUND

The prognosis of advanced colorectal cancer after surgical resection remains poor if curative resection cannot be achieved. Neoadjuvant chemotherapy( NAC) may increase the curative resection rate and reduce the recurrence rate following resection of marginally resectable advanced colorectal cancer by ensuring adequate surgical margin and controlling micro-metastases. Herein, we report the treatment regimen and outcomes of NAC for advanced colorectal cancer at our institute.

PATIENTS AND METHODS

Between April 2005 and December 2012, 10 patients with marginally resectable advanced colorectal cancer received NAC before undergoing laparotomy. NAC consisted of 4 to 8 courses of the FOLFIRI-3 regimen combined with molecular targeted agents. Laparotomy was performed 4 to 6 weeks after the last course of NAC, and 12 courses of mFOLFOX6 were recommended as adjuvant chemotherapy after surgery.

RESULTS

A partial response (PR) according to Response Evaluation Criteria in Solid Tumors ver. 3 was observed in 5 patients and progressive disease (PD) was not observed in any patient. Curative resection was achieved in 9 patients. All patients are currently alive, and the 2-year relapse-free survival rate was 62.2%.

CONCLUSIONS

This is a retrospective study of a small number of subjects; however, the results suggest that NAC for marginally resectable advanced colorectal cancer increases the curative resection rate and reduces the recurrence rate.

[Evaluation of tumor heterogeneity for esophageal squamous cell cancer by dynamic FDG-PET]

The aim of this study is to assess the tumor heterogeneity of esophageal squamous cell cancer by dynamic FDG-PET (dPET). Thirty patients were enrolled in this study. Images were obtained after intravenous injection of 370 MBq of 18F-FDG for 1 h. The time-density curve of the standardized uptake value( SUV) was evaluated quantitatively by fractal analysis. Tumor fractal dimension (FD) maps were acquired, and the FD of the tumor was measured. There was a significant correlation between FD and the clinical response to adjuvant therapy. The FD reduction rates of adjuvant therapy were 23.23% in the responder group and 5.83% in the nonresponder group. FD may be a valid imaging biomarker for assessing the response to neoadjuvant therapy.

Utility of arterial phase of dynamic CT for detection of intestinal ischemia associated with strangulation ileus

AIM: To clarify the usefulness of arterial phase scans in contrast computed tomography (CT) imaging of strangulation ileus in order to make an early diagnosis.

METHODS: A comparative examination was carried out with respect to the CT value of the intestinal tract wall in each scanning phase, the CT value of the content in the intestinal tract, and the CT value of ascites fluid in the portal vein phase for a group in which ischemia was observed (Group I) and a group in which ischemia was not observed (Group N) based on the pathological findings or intra-surgical findings. Moreover, a comparative examination was carried out in Group I subjects for each scanning phase with respect to average differences in the CT values of the intestinal tract wall where ischemia was suspected and in the intestinal tract wall in non-ischemic areas.

RESULTS: There were 15 subjects in Group I and 30 subjects in Group N. The CT value of the intestinal tract wall was 41.8 ± 11.2 Hounsfield Unit (HU) in Group I and 69.6 ± 18.4 HU in Group N in the arterial phase, with the CT value of the ischemic bowel wall being significantly lower in Group I. In the portal vein phase, the CT value of the ischemic bowel wall was 60.6 ± 14.6 HU in Group I and 80.7 ± 17.7 HU in Group N, with the CT value of the ischemic bowel wall being significantly lower in Group I; however, no significant differences were observed in the equilibrium phase. The CT value of the solution in the intestine was 18.6 ± 9.5 HU in Group I and 10.4 ± 5.1 HU in Group N, being significantly higher in Group I. No significant differences were observed in the CT value of the accumulation of ascites fluid. The average difference in the CT values between the ischemic bowel wall and the non-ischemic bowel wall for each subject in Group I was 33.7 ± 20.1 HU in the arterial phase, being significantly larger compared to the other two phases.

CONCLUSION: This is a retrospective study using a small number of subjects; however, it suggests that there is a possibility that CT scanning in the arterial phase is useful for the early diagnosis of strangulation ileus.

[Neoadjuvant chemotherapy for recurrent colorectal cancer]

BACKGROUND

The prognosis after surgical resection of recurrent colorectal cancer is still poor, even if it is diagnosed as "resectable" before operation. Neoadjuvant chemotherapy (NAC) may reduce the recurrence rate after resection of recurrent lesions by ensuring the surgical margin and controlling micro-metastases. This report presents the treatment regimen and outcome of NAC for recurrent colorectal cancer at this institution.

PATIENTS AND METHODS

Nineteen patients with recurrent colorectal cancer, excluding hepatic and pulmonary metastases, received NAC before laparotomy between April 2005 and November 2011. The FOLFIRI3 regimen combined with molecular targeting agents was used for NAC, and 4 to 8 courses were administered. Laparotomy was performed during the 4-to 6-week period after the last NAC administration, and 12 courses of mFOLFOX6 were recommended as adjuvant chemotherapy after the operation.

RESULTS

Complete remission was observed in 1 patient and partial remission in 7 patients according to Response Evaluation Criteria in Solid Tumors ver. 3, and no progressive disease was observed. Curative resection was achieved in 13 patients. The 3-year overall survival rate was 83.6%, and the 3-year relapse-free survival rate was 50.3%.

CONCLUSION

This retrospective study using a small number of subjects suggested that NAC for recurrent colorectal cancer may increase the curative resection rate while reducing the recurrence rate.

Tracheal compression by the gastric tube in esophageal cancer with ankylosing spondylitis and an analysis of the mediastinal condition in 84 cases of esophagectomy: report a case

Pneumonia, recurrent nerve injury and anastomotic leakage are common complications occurring after esophagectomy. However, there have so far been few reports on tracheal compression by the gastric tube. The patient was a 66-year-old female with a history of ankylosing spondylitis and esophageal superficial squamous carcinoma treated with endoscopic mucosal resection. The new lesion was located just next to the last treated lesion. Therefore, it was difficult to treat this lesion endoscopically because of severe stenosis and scarring due to the previous treatment. Transhiatal esophagectomy was therefore performed. However, severe tracheal obstruction occurred following extubation after the surgery due to compression caused by the gastric tube. This case was successfully treated with a mediastinal pleural incision through a right thoracotomy. The distance between the sternum and the vertebra in this case was narrower than normal, thereby inducing this rare condition.

[A case of recurrent rectal cancer with idiopathic thrombocytopenic purpura showing rapid progression, suggesting disseminated intravascular coagulopathy]

A 64-year-old female with idiopathic thrombocytopenic purpura(ITP)was admitted to our hospital under the diagnosis of rectal cancer. Intersphincteric resection and splenectomy were performed after high-dose gamma globulin therapy. Thirteen months after the surgery, she suffered from a local recurrence and groin and pelvic lymph node metastases. Radiotherapy was planned before curative resection. During radiation, she complained of severe back pain and high fever with severe thrombocytopenia, and was admitted to our hospital. The examinations revealed disseminated intravascular coagulopathy(DIC), probably induced by multiple bone and hepatic metastases. Although anti-DIC therapy and chemotherapy with FOLFIRI were performed, thrombocytopenia did not improve, and she died of cancer progression about 2 months after admission. We report a case ofDIC induced by cancer progression with ITP. Since thrombocytopenia may be induced by either DIC or ITP, selecting a treatment for such a patient is difficult. We report the present case in detail and discuss findings from the literature.

[Regional treatment of esophageal liver metastasis by intra-arterial low-dose 5-FU therapy]

The prognosis of esophageal liver metastasis remains poor because of the high incidence of synchronous metastasis in other area and insufficient response to systemic chemotherapy. We assessed loco-regional anticancer potential of intra-arterial 5-FU chemotherapy for esophageal liver metastasis aimed at combination with systemic chemotherapy, radiotherapy and ablation therapy as a multidisciplinary treatment. Six patients of esophageal cancer with liver metastasis and without extra-hepatic metastasis were enrolled. Intra-aortic chemotherapy consisted of 5-FU (250 mg/body) in a one-shot infusion or a continuous infusion for 7 days with 2-week intervals until failure. The responses of liver metastasis were 2 cases of CR, 3 of PR and 1 of SD. The response rate and the local control rate were 83% and 100%, respectively. The maximum time to progression was 53 months. Grade 3/4 toxicity was not observed. Two cases had catheter failure and the treatment was interrupted. Liver metastases were controlled well until death in all cases except one. Low-dose intra-aortic 5-FU chemotherapy provided a good regional response and a combination with systemic chemotherapy may prolong survival for the patients of liver metastasis of esophageal cancer.

[Diffusion-weighted MR imaging for postoperative nodal recurrence of esophageal squamous cell cancer in comparison with FDG-PET]

We evaluated the power of DWIBS in patients with postoperative lymph node recurrence of esophageal cancer and compared with FDG-PET findings. Forty-seven suspected lesions by MDCT were enrolled. No significant difference between DWIBS and PET was observed in sensitivity (95% vs 97%), PPV (83% vs 90%) and overall accuracy rate (81% vs 87%). The ADCs (x10(-3) mm2/s) of recurrent nodes, primary cancer and normal esophagus were 1.124, 1.058 and 2.079, respectively. ADCs of recurrent nodes were significantly lower than those of normal esophagus (p<0.0001). The cut-off ADC line of 1.5 revealed 100% overall accuracy for separating the recurrent lesion from normal esophagus. Noninvasive DWIBS may become a valid modality to discriminate nodal recurrence of esophageal cancer by no means inferior to PET.

Anatomy of the middle hepatic vein: applications to living donor liver transplantation

BACKGROUND/AIMS

In living donor liver transplantation, right lobe graft without a middle hepatic vein (MHV) results in potential venous congestion in the anterior segment, while transplantation with MHV represents an important ethical issue from the perspective of donor safety. The present study assessed ramification patterns of the MHV and relationships between hepatic venous drainage of the anterior and medial segments, to plan optimal harvesting of the right lobe as a graft.

METHODOLOGY

The authors reviewed 102 patients with normal livers who underwent contrast-enhanced multi-detector row CT.

RESULTS

The hepatic vein that drained S4sup (V4sup) joined only the left hepatic vein (LHV) in 60 patients (58%), only the MHV in 25 (25%), and both LHV and MHV in 17 (17%). Both V4sup and the hepatic vein that drained S8 (V8) joined the MHV in 42 patients (42%), and V8 joined proximal to V4sup in 18 of these 42 patients.

CONCLUSIONS

In donation of a right lobe graft including MHV, preservation of V4sup in the remnant donor liver seems possible in most donors.

The blood supply of the hilar bile duct and its relationship to the communicating arcade located between the right and left hepatic arteries

BACKGROUND

There is an increasing demand for living donor liver transplants. However, the biliary complication rates are still high.

METHODS

The anatomy of the communicating arcade (CA) between the right and left livers and its relevance to the blood supply of the hilar bile duct was evaluated using adult cadaveric livers and cast specimens.

RESULTS

In all specimens that were of sufficient quality for evaluation, the CA was found to be located extrahepatically in the hilar plate with thin tributaries branching to the hilar bile duct. On the left side, 55% of the CA originated from a segment IV artery. On the right side, 73% of the CA originated from the right anterior hepatic artery.

CONCLUSIONS

To maintain an adequate blood supply for the hilar bile duct of the donor graft during living donor liver transplantation, the branching point of the CA should be preserved.

Successful resection of a liver metastasis from AFP-producing pancreatic cancer resulting in long-term survival: a case report and review of literature

The prognosis of patients with alpha-fetoprotein (AFP)-producing pancreatic cancer is generally very poor. We, however, present a case of a 33-year-old man who survived AFP-producing pancreatic cancer and its metachronous liver metastasis. The patient had undergone a curative total pancreatectomy for AFP-producing pancreas head cancer invading to the tail, which was postoperatively confirmed by immunohistochemical staining of the resected specimen. At 1 year and 4 months after the operation, the serum AFP level was elevated to 26 ng/mL, and a 2.6 cm-sized mass was found in the lateral segment of the liver. He underwent lateral segmentectomy, and the tumor was histopathologically diagnosed as having metastasized from the AFP-producing pancreatic cancer removed earlier. The patient is doing well 8 years and 5 months after resecting the liver metastasis, with no signs of recurrence. This case suggests that surgery may also be a treatment of choice for patients with liver metastasis from AFP-producing pancreatic cancer, particularly for those with a metachronous and solitary tumor. It should be remembered that some pancreatic cancers produce AFP and that monitoring of postoperative serum AFP levels in such cases will be useful for early detection of recurrence and selection of appropriate surgical intervention.

Two-staged hepato-pancreatoduodenectomy and interventional pancreaticojejunostomy

Two-staged pancreatoduodenectomy, including exteriorization of the pancreatic juice and second-look pancreaticojejunostomy, has been recommended for high-risk patients to avoid pancreatic leakage, which often causes intra-abdominal hemorrhage. We present a new technique of interventional pancreaticojejunostomy under both fluoroscopy and endoscopy without second-look laparotomy. A 77-year-old woman with local recurrence and liver metastasis from colon cancer underwent hepato-pancreatoduodenectomy with the external drainage of pancreatic juice via the pancreatic duct tube without pancreaticojejunostomy. Two months later, the jejunum was punctured with the insertion of a 5-F needle-knife into the pancreatic fistula during endoscopic observation of jejunal lumen, followed by the insertion of two 0.35-inch guidewires into the jejunum and the pancreatic fistula. Finally, a 10-Fr stenting tube was placed between the jejunum and the pancreatic fistula. No complications developed.

Communicating arcade between the right and left hepatic arteries: evaluation with CT and angiography during temporary balloon occlusion of the right or left hepatic artery

PURPOSE

To evaluate prospectively the relationship between the arterial collateral system at the hepatic hilum and the blood supply to the hilar bile duct by using computed tomography (CT) and angiography during temporary balloon occlusion of the right or left hepatic artery.

MATERIALS AND METHODS

Institutional review board approval and informed consent were obtained. The study included 13 patients with no lesions at the hepatic hilum (eight men and five women; age range, 41-78 years; mean, 65.8 years). After serial angiographic studies were performed for preoperative evaluation or transcatheter arterial chemoembolization, a 5.5-F catheter with an occlusion balloon was positioned in the right or left hepatic artery. Eleven patients underwent angiography of the left hepatic artery with temporary occlusion of the right hepatic artery, and two patients underwent angiography of the right hepatic artery with temporary occlusion of the left hepatic artery. In addition, 11 patients underwent single-level dynamic CT during hepatic arteriography (CTHA) with temporary occlusion of the right or left hepatic artery. The images from angiography and CTHA were interpreted by two authors who assessed the existence of the arterial communication and its branching points, location, and relationship to the hilar bile duct and caudate lobe.

RESULTS

During temporary occlusion of the right or left hepatic artery, the communicating arcade (CA) between the right and left hepatic arteries was immediately evident in all patients. On the left side, the CA originated from the segment IV artery in eight patients (62%) and from the left hepatic artery in five (38%). On the right side, the CA originated from the right anterior hepatic artery in six patients (46%), the right hepatic artery in two (15%), and both arteries in five (38%). The CA was extrahepatically located close to the hilar bile duct and forked into a few branches to the caudate lobe.

CONCLUSION

The CA may play an important role not only in the interlobar arterial collateral system but also in the blood supplies to the caudate lobe and hilar bile duct.

Overexpression of glucose transporter 1 in esophageal squamous cell carcinomas: a marker for poor prognosis

Recently, Glut1 (human erythrocyte glucose transporter) expression has been demonstrated in various tumors. The aim of this study is to evaluate the prognostic utility of Glut1 expression in esophageal carcinomas. We studied Glut1 expression by immunohistochemistry of paraffin sections from 63 esophageal squamous cell carcinomas. All 63 carcinomas expressed Glut1. The mean percentage of positively stained tumor cells was 77.8% (median, 84.7%). There were two staining patterns in positive cells: 'strongly positive' and 'weakly positive'. The percentage of 'strongly positive' cells (%Glut1-SP) ranged from 0% to 95.6% (mean, 32.3%; median, 27.4%). The 5-year survival rate for patients with a high %Glut1-SP (> 30%) was significantly lower than that for patients with a low %Glut1-SP (< 30%) (P < 0.01). Statistical analysis revealed that the relative risk of death for patients with high %Glut1-SP was 2.02 times that for patients with low %Glut1-SP (P = 0.064), suggesting a possible independent predictive value for %Glut1-SP.

Anterior fissure of the right liver--the third door of the liver

BACKGROUND/PURPOSE

Although the anterior segment of the liver has been divided into segments 8 and 5, we have, during surgical or interventional procedures, occasionally encountered patients in whom the right anterior portal vein does not bifurcate into the superior and inferior branches. Thus, the in vivo anatomy of the right liver was reevaluated to clarify the segmental anatomy.

METHODS

We evaluated the hepatic venous and portal ramification patterns, using three-dimensional images reconstructed from computed tomography. In addition, liver volumetry was performed.

RESULTS

All branches arising from the anterior trunk were divided into two groups: the right ventral portal branches (RVP) and the right dorsal portal branches (RDP), and the anterior fissure vein crossed between the RVP and RDP. The ventral and dorsal regions of the anterior segment were approximately equal from a volumetric point of view.

CONCLUSIONS

The anterior segment seems to be divided into the ventral and dorsal segments by the anterior fissure, and we propose a reclassification of the right liver that divides the right liver into three segments. Dissection of the parenchyma along the anterior fissure makes the third door of the liver open, resulting in the exposing of all Glissonian pedicles of the right liver. The introduction of our segmental anatomy and surgical procedure will allow more systematic and limited liver resections.

Proposal for a reclassification of liver based anatomy on portal ramifications

BACKGROUND

Portal branching patterns that differ from those previously described are occasionally encountered during liver surgery.

METHODS

A total of 60 patients with normal intrahepatic venous anatomy underwent helical computed tomography during arterial portography (CTAP). Next, 3 dimensional portograms were reconstructed to verify the locations of the portal veins. Portal branching patterns in the right hemiliver were assessed.

RESULTS

In all 60 patients examined, the right anterior portal vein bifurcated into the ventral and dorsal branches. In 42 (70%) of 60 patients, some branches arose from the right posterior portal trunk. Between 1 and 3 branches (mean 2.3 branches per patient) coursed cranially, between 2 and 5 branches (mean 3.2 branches per patient) coursed caudally, and between 1 and 2 branches (mean 1.3 branches per patient) coursed laterally.

CONCLUSIONS

We propose that the right liver should be divided into 3 segments, which are designated as the right anterior, middle, and posterior segments.

Relationship between glucose transporter, hexokinase and FDG-PET in esophageal cancer

BACKGROUND/AIMS

18F-fluorodeoxyglucose positron emission tomography (FDG-PET) has been established as a powerful diagnosing modality in clinical oncology. FDG accumulation has been demonstrated to correlate with hexokinase activity. However, recent reports suggest that glucose transporters participate in FDG accumulation. The aim of this study is to evaluate glucose transporter and hexokinase expression and clarify the relationship between them and FDG accumulation.

METHODOLOGY

FDG-PET was performed in 72 preoperative patients with esophageal cancer. The ratios of tumor radioactivity to plasma radioactivity (Ci/Cp values) were obtained 60 minutes after administration. We studied the expressions of glucose transporter 1 (Glut1) and type-II hexokinase (HK-II) by immunohistochemical analysis of the resected specimen. The percentages of cells expressing Glut1 and HK-II were scored on a 5-point scale (1=0-20%, 2=20-40%, 3=40-60%, 4=60-80%, 5=80-100%). Then the 3 scores obtained from 3 counting trials were averaged to give the Glut-index and HK-index.

RESULTS

All esophageal cancers showed marked FDG accumulation. All 72 cancers expressed Glut1 and 71 of 72 cancers expressed HK-II. The Glut-index had a weak correlation with the Ci/Cp value (not significant). The HK-index had a close positive correlation with the Ci/Cp value (p<0.005).

CONCLUSIONS

FDG accumulation correlates more with type-II hexokinase expression than with glucose transporter 1 expression.

Limited resection of the right hemiliver based on reclassification of the right anterior segment of the liver

We proposed that the anterior segment was divided into ventral and dorsal segments, and reclassified the right hemiliver into three segments; ventral, dorsal, and posterior segments. According to our classification we successfully performed limited resection of the right hemiliver.

Limited resection based on reclassification of segment 8 of the liver

Liver vein patterns which differ from those previously described are occasionally encountered during surgery. Therefore, we reclassified the anterosuperior segment (S8) into S8v (ventral area) and S8d (dorsal area), and the right paramedian sector into the ventral segment (S8v+S5) and the dorsal segment (S8d) based on portal and hepatic vein patterns. Using this new classification, we performed three types of limited resection of S8 in six patients with neither major nor minor procedural complications including biliary leaks, and no blood transfusion. This new classification allows development of surgical procedures where resection is limited to the portal unit and tumor.

Successful treatment of lymph node metastases recurring from gallbladder cancer

A 66-year-old woman who had undergone cholecystectomy for the treatment of gallbladder cancer 5 years and 10 months previously was referred to our center due to increased carbohydrate antigen (CA)19-9. Increased CA19-9 (136U/ml) was the only abnormality detected on initial examination, and, despite various tests, clear signs of recurrence could not be detected. Subsequently, the patient was followed. Six months after the initial examination, dynamic computerized tomography confirmed lymphadenopathy. The results of fluoro-deoxy-glucose positron emission tomography suggested lymph node metastasis of the gallbladder cancer, and after consideration of the site of recurrence and the length of time between the primary surgery and detection of recurrence, the patient underwent extrahepatic bile duct resection and lymphadenectomy. Levels of CA19-9 normalized postoperatively, and, at the time of writing (26 months postoperatively), blood tests and diagnostic imaging revealed no signs of recurrence.

Use of an occlusion balloon catheter during laparotomy for control of postoperative bleeding after pancreatoduodenectomy

Pancreatoduodenectomy has become safer, but postoperative complications, including life-threatening intraperitoneal bleeding, are still relatively common. We recently treated intraperitoneal bleeding after pancreatoduodenectomy by performing a laparotomy in conjunction with the use of a large occlusion balloon catheter. Angiography had failed to identify the site of bleeding in this patient. Our experience suggests that using a large occlusion balloon catheter to control bleeding effectively maintains an adequate surgical field in patients requiring laparotomy for hemostasis.

[Treatment of colorectal cancer--hepatic metastases]

The aim of this study was to evaluate the effect of the local therapy for colorectal liver metastases on overall survival. Seventy-two patients who had resected liver metastases from colorectal cancer during the period from 1982 to 2001 were evaluated for survival. There was no significant difference in overall survival by either surgical method for colorectal liver metastases or postoperative arterial infusion chemotherapy. However, the 5-year survival rate of resected metachronous liver metastases with postoperative arterial infusion chemotherapy was 44.9%, and that for patients with no extra hepatic metastases was 57.4%. Patients who have metachronous liver metastases from colorectal cancer should therefore be considered for postoperative arterial infusion chemotherapy. It is necessary to improve the outcome for cases that have extra hepatic metastases.

Effects of a new antiallergic drug, VUF-K-8788, on infiltration of lung parenchyma by eosinophils in guinea pigs and eosinophil-adhesion to human umbilical vein endothelial cells (HUVEC)

Airway inflammation and reversible airway obstruction are hallmarks of bronchial asthma. In this study, we investigated the effects of a new antiallergic drug, 7-[3-[4-(2-quinolinylmethyl)-1-piperazinyl]-propoxy]-2,3-dihydro-4H-1,4-benzothiazin-3-one (VUF-K-8788), on histopathological changes in lung parenchyma of guinea pigs during late-phase asthmatic reaction (LAR), and on eosinophil-adhesion to human umbilical vein endothelial cells (HUVEC). Repeated exposure to ovalbumin of sensitized guinea pigs induced inflammatory phenomena such as hyperplasia of airway epithelial cells, perivascular edema and infiltration of lung parenchyma by eosinophils. VUF-K-8788 inhibited these histopathological phenomena at 10 mg/kg p.o. Moreover, the eosinophil-adherence to HUVEC was inhibited by VUF-K-8788 at the concentration of 10-30 microM. In conclusion, this inhibitory effect of VUF-K-8788 on eosinophil-adherence might contribute to the prevention of LAR and infiltration by eosinophils in the experimental asthmatic model in guinea pigs.

Combination chemotherapy with ifosfamide, 5-fluorouracil, etoposide and cisplatin for metastatic urothelial cancer

PURPOSE

To investigate the activity of combination chemotherapy with ifosfamide, 5-fluorouracil, etoposide and cisplatin in patients with metastatic urothelial cancer.

METHODS

A group of 29 patients were treated with 2000 mg/m2 ifosfamide, 750 mg/m2 5-fluorouracil, 100 mg/m2 etoposide and 20 mg/m2 cisplatin. All four drugs were given intravenously on days 1 through 3 and the treatment was repeated every 3 weeks. Of the 29 patients, 14 had lymph node metastasis alone, and 15 had visceral lesions.

RESULTS

An objective response was achieved in 17 patients (59%). There was no difference in response rates according to metastatic site including osseous lesions, which responded well in four of six patients. The 3-year survival rate for all patients was 16% with four patients who had undergone salvage surgery being alive with no evidence of disease 15 to 61 months after initiation of the treatment. A good performance status, lymph node metastasis alone and administration of chemotherapy at the full dosage had a significantly favorable impact on patient survival. Bone marrow toxicity was significant and one patient died of treatment-related sepsis.

CONCLUSIONS

Ifosfamide, 5-fluorouracil, etoposide and cisplatin combination chemotherapy appeared to be active in the treatment of metastatic urothelial cancer. Although bone marrow toxicity was significant, the treatment was well tolerated by the majority of the patients. Further study may be warranted.

VUF-K-8788, a periphery-selective histamine H1 antagonist with anti-pruritic activities

The pharmacological properties of 7-[3-[4-(2-quinolinylmethyl)-1-piperazinyl]-propoxy]-2,3-dihydro-4H-1,4-benzothiazin-3-one (VUF-K-8788) were investigated in vitro and in vivo. VUF-K-8788 inhibited [3H]-mepyramine from binding to the cell membrane of lung parenchyma (Ki value: 5.0 nM) and the histamine-induced contraction of isolated guinea pig ileum (pA2: 9.71) without affecting ileal contractions induced by acetylcholine, serotonin, KCl and BaCl2. The increase of vascular permeabilities induced by histamine and passive cutaneous anaphylaxis (PCA) in guinea pigs were inhibited by VUF-K-8788 in a dose-dependent fashion (ED50: 0.24 and 0.26 mg/kg, p.o., respectively). Moreover, the anti-histaminic effect of VUF-K-8788 was also observed in rats. In experiments on the effects on the central nervous system, VUF-K-8788 at 1 mg/kg, p.o. hardly antagonized the H1 receptor at all in the cerebral cortex of guinea pigs. VUF-K-8788 inhibited the PCA-induced scratching behavior completely without affecting thiopental-induced sleep in mice. These results suggested that VUF-K-8788 would be useful in the treatment of allergic disorders such as atopic dermatitis and eczema.

Functional disomy for Xq26.3-qter in a boy with an unbalanced t(X;21)(q26.3;p11.2) translocation

A nine-month-old boy, with functional disomy for Xq26-qter and multiple congenital abnormalities, is reported. The boy had severe pre- and postnatal growth retardation, profound developmental delay, hypotonia, microcephaly, agenesis of the corpus callosum, dysmorphic facial features, cryptorchidism, and left multidysplastic kidney. He developed feeding difficulties and infantile spasms. G-banding analysis of his chromosomes showed additional material on the short arm of chromosome 21. His parents refused to submit to chromosome analysis. Analysis with chromosome microdissection followed by reverse and forward chromosome painting indicated his karyotype as 46,XY,der(21)t(X;21)(q26;p11.2). This is the first description of pure functional disomy for Xq26-qter due to an unbalanced X-autosome translocation.

Craniofacial and dental characteristics of Kabuki syndrome

We describe oral manifestations in six patients (three females and three males aged 6 to 24 years) with Kabuki syndrome (KS), based on their physical, orthopantomographic, and cephalometric findings. All six patients had a high-arched palate, malocclusion, most commonly unilateral posterior cross-bite (5/6), severe maxillary recession and mid-facial hypoplasia. Other frequently observed oral manifestations included small dental arch and hypodontia. Three patients lacked permanent teeth, mostly the central/lateral incisors. Both tooth size (in primary and permanent teeth) and dental arch (in length and width) tended to be small. We would like to stress that oral care and management is a must for the well-being of KS patients.

Molecular cytogenetic analysis of eight inversion duplications of human chromosome 13q that each contain a neocentromere

Neocentromeres are fully functional centromeres that have arisen in previously noncentromeric chromosomal locations on rearranged chromosomes. The formation of neocentromeres results in the mitotic stability of chromosomal fragments that do not contain endogenous centromeres and that would normally be lost. Here we describe a unique collection of eight independent patient-derived cell lines, each of which contains a neocentromere on a supernumerary inversion duplication of a portion of human chromosome 13q. Findings in these patients reveal insight into the clinical manifestations associated with polysomy for portions of chromosome 13q. The results of FISH and immunofluorescent analysis of the neocentromeres in these chromosomes confirm the lack of alpha-satellite DNA and the presence of CENtromere proteins (CENP)-C, -E, and hMAD2. The positions of the inversion breakpoints in these chromosomes have been placed onto the physical map of chromosome 13, by means of FISH mapping with cosmid probes. These cell lines define, within chromosome 13q, at least three distinct locations where neocentromeres have formed, with five independent neocentromeres in band 13q32, two in band 13q21, and one in band 13q31. The results of examination of the set of 40 neocentromere-containing chromosomes that have thus far been described, including the 8 neocentromere-containing chromosomes from chromosome 13q that are described in the present study, suggest that chromosome 13q has an increased propensity for neocentromere formation, relative to some other human chromosomes. These neocentromeres will provide the means for testing hypotheses about sequence requirements for human centromere formation.