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In a case of retroperitoneal dedifferentiated mixed-type liposarcoma, a dedifferentiated component was observed in the so-called mixed-type liposarcoma consisting of well-differentiated and myxoid components. The proliferative activity was compared among the different components of the tumor by immunohistochemical study using the proliferating cell nuclear antigen (PCNA) and MIB-1 monoclonal antibodies. The dedifferentiated component showed higher positivity than the well-differentiated and myxoid components, and tumor progression was most advanced in the dedifferentiated component. In the chronological examination of each component, the labeling indices of PCNA and MIB-1 were significantly higher at the third recurrence than in the primary lesion in all types, indicating that the proliferative activity of the tumor cells increased gradually. Considering the surgical treatment of liposarcoma, an extended resection encompassing normal adjacent tissues is required in cases containing the dedifferentiated component in comparison to the cases containing only well-differentiated or myxoid components.

During the last seven years, 17 patients underwent microsurgical reconstruction of 14 hepatic and four superior mesenteric arterial systems following extended pancreatectomy or hepatectomy, and in living-related liver transplantations (LRLT). All microvascular anastomoses in this series were performed using a back wall technique, in which the microsutures are placed in the back wall of the vessel first, and turning over of the microclamp is eliminated. This back wall technique is useful for microvascular reconstruction in a deep abdominal cavity in which there is no room to turn over the microclamp. In LRLTs, even if the hepatic artery of the graft liver is so short that the microclamp on it cannot be rotated, this technique overcomes such difficult situations. Microvascular anastomosis without turning over the clamp is superior to the conventional method in terms of reducing intimal damage to the vessels. The vessels located vertical to the microvascular surgeon are smoothly anastomosed using this technique. The authors advocate this back wall technique as advantageous in microsurgical reconstructions of the hepatic and superior mesenteric arterial systems.

Background . We evaluated the efficacy of tracheal patch reconstruction with a covered expandable metallic stent (EMS) with omentoplasty. Methods . After resecting the right half of the circumferential wall of two tracheal rings in adult beagle dogs, we inserted a covered EMS to reconstruct the defect interiorly. Then, through laparotomy, we made an omental pedicle flap and wrapped it around the EMS-interposed area. For comparison with the group without omentoplasty, we periodically examined the healing process macroscopically and histologically. Results . Bronchofiberscopic observations revealed that incorporation of the covered EMS progressed with the passage of time and tracheal luminal patency was maintained well in both groups. However, polyplike granulation developed gradually at both ends of the EMS. Histologically, epithelium was regenerated in the patched area 4 weeks postoperatively and the area was covered with pseudostratified ciliated epithelium at 12 weeks postoperatively. Quantitative analysis of the macroscopic and histologic findings showed that the inflammatory polyps were reduced and epithelialization was promoted in the group with omentoplasty. Conclusions . Tracheal patch reconstruction with a covered EMS, when combined with omentoplasty, promoted early epithelial regeneration and suppressed the development of inflammatory polyps.

Total pharyngoesophageal reconstruction has remained a challenging field in digestive surgery. During the past 3 years, the authors performed six microsurgical reconstructions of the digestive tract following pharyngolaryngectomy and total esophagectomy due to a multiple cancer or skip metastasis. Digestive continuity was restored using a combination of a pulled-up gastric pedicle and free jejunal transfer in 2 patients, and an elongated gastric pedicle with microvascular augmentation in 4 patients. One elongated gastric pedicle developed partial necrosis, and a free jejunal graft was placed additionally. One patient suffered from respiratory dysfunction and died 1 month after surgery. Postoperative radiographic examination showed a good swallowing mechanism without reflux and stasis in all patients. Microvascular surgery contributes to the successful reconstruction of the digestive tract following extensive pharyngolaryngoesophagectomy.

Background and Objectives The correlation between various levels of perineural invasion by pancreatic carcinoma and the patient's prognosis has never been cleared. The authors carried out a histopathologic study of resected pancreatic carcinoma to elucidate the significance of a new histologic finding concerning perineural invasion, which we designated “ntrapancreatic, extratumoral perineural invasion (nex),” and also to determine its predictive value for prognoses of patients after surgical removal of the tumor. Methods We investigated 90 patients with pancreatic adenocarcinoma who had undergone pancreatic resection. The prognoses of all patients were explored, and correlations between survival and pathologic factors were statistically examined for neural invasion. Results Nex was found in more than 50% of resected pancreases. A statistically significant association was found between the presence of nex and the grade of intrapancreatic neural invasion or the presence of extrapancreatic neural plexus invasion. Nex was also found to be associated with patient survival after removal of the tumor. Conclusions Nex appears to be an element predicting pancreatic cancer infiltration to the extrapancreatic nerve plexus and also to be a factor influencing postoperative survival of patients with pancreatic carcinoma. J. Surg. Oncol. 1997;65:164–170. © 1997 Wiley-Liss, Inc.

Our experience with four patients who underwent immediate reconstruction following total laryngopharyngoesophagectomy and extensive resection of the superior mediastinum is presented. The reconstructive procedures included free jejunal graft or microvascularly augmented gastric pedicle for esophageal reconstruction, pectoral fasciocutaneous or myocutaneous flap for tracheal reconstruction, and mesenteric flap connected with jejunal graft omental flap, or pectoral flap for protection of the great vessels and obliteration of the dead space in the cervical and superior mediastinal region. The reconstructive procedures were successful, and no pharyngocutaneous fistula, mediastinitis, or great vessel rupture was noted in any patient. There was one patient who developed lung edema and liver dysfunction postoperatively. Combinations of reconstructive procedures using well-vascularized soft tissues can be expected to provide well-tolerated reconstruction following extensive cervical and superior mediastinal resection.

Duodenum-preserving resection of the head of the pancreas was performed in 41 patients with chronic pancreatitis and 23 with pancreatic neoplastic lesions. Denervation of the body and tail of the pancreas was added for the patients with chronic pancreatitis. The major advantage of this procedure is that only the small pancreas head is resected, leaving the endocrine and exocrine systems functioning normally. This procedure provides complete pain relief for the patients with chronic pancreatitis; 92% of patients experienced alleviation of pain and no recurrence. Postoperatively, 76% of patients could work well, and 87% maintained their preoperative body weight. Postoperative glucose tolerance test showed 21% of the patients with preoperative diabetic pattern improved to the nondiabetic pattern between 3 months and 3 years after surgery. In 23 patients with pancreatic neoplasms, 22 patients were alive during the follow-up period with no recurrence of the tumor, except 1 patient who died of acute myocardial infarction. We concluded that our procedure allows, patients with chronic pancreatitis to be free from intractable pain and to maintain good endocrine function of the pancreas. Furthermore, this procedure can be applied to patients with low-grade malignant lesions of the pancreas.

A 62-year-old woman was examined with In-111 pentetreotide and Ga-67 citrate. She had undergone an operation to resect a neuroendocrine tumor of the pancreas and still had masses in the liver. One of her hepatic lesions had been biopsied and acinar cell carcinoma was suspected. Fluid in the cyst of the tumor, however, contained a high concentration of gastrin and the tumor was strongly suspected of being a metastasis from the neuroendocrine tumor of the pancreas. The hepatic tumors quickly accumulated In-111 pentetreotide immediately after the injection, but there was no Ga-67 citrate uptake in the tumor. Five months after pentetreotide scintigraphy, her hepatic tumors were resected and histologically proven to be metastasis of islet cell carcinoma. In-111 pentetreotide provides information of the somatostatin-receptor status on the tumor and supports the diagnosis made by hormonal survey.

Background Locally advanced cancer of the pancreatic body involving the celiac and/or common hepatic arteries is often considered unresectable. Radical distal pancreatectomy with en bloc resection of these arteries without reconstruction was recently introduced to treat these tumors. However, experience is still limited. This study reviewed the safety and utility of the operation. Patients and methods We retrospectively studied the charts of 13 patients who underwent radical distal pancreatectomy. Results Unplanned arterial reconstruction was required in three patients due to accidental injury. The postoperative mortality rate was 0% despite a morbidity rate of 62%. Patient's intractable abdominal and/or back pain was completely relieved immediately after surgery. Contrary to expectations, postoperative diarrhea was mild. The surgical margins, including the retroperitoneum, were clear histologically (R0 resection) in all patients. The 1- and 2-year survival rates were 51% and 14%, respectively, and median survival was 12.2 months. The site of recurrence was the liver in six patients and retroperitoneum in one. Conclusions Distal pancreatectomy with en bloc resection of the celiac artery is feasible and safe, offers a high resectability rate, and has dramatic analgesic effect. Local control of disease is excellent despite frequent hepatic recurrence.

肝動脈瘤に対する経動脈カテーテル塞栓術(以下塞栓術)について,自験5例を含めた本邦報告69例を集計し,塞栓術の適応,手技上の要点,合併症,治療成績の問題点に考察を加えた.治療法の選択と密接な関係にある発生原因,発生部位は,医原性の増加により外傷性,肝内動脈に多く,診断に引き続いて施行可能な塞栓術の適応は拡大している.他部位との吻合のない実質臓器動脈では中枢のみの塞栓で永久治療効果が得られるのでsteel coilを用いSpongel角片で補填する方法が最も有効である.留意すべきは胃十二指腸動脈切断時の総肝動脈,固有肝動脈の塞栓で下横隔膜動脈を主体とする側副路の確認が必要であり,balloon閉塞下外科手術の適応となる場合もある.最も問題となるのは,止血効果が良好な予後に直結しないことであるが,短時間で急速な止血効果の得られる塞栓術は外科治療に先だって考慮すべき方法である.