Bleeding from esophageal varices (EVs) is a catastrophic complication of chronic liver disease. Many years ago, surgical procedures such as esophageal transection or distal splenorenal shunting were the only treatment...Bleeding from esophageal varices (EVs) is a catastrophic complication of chronic liver disease. Many years ago, surgical procedures such as esophageal transection or distal splenorenal shunting were the only treatments for EVs. In the 1970s, interventional radiology procedures such as transportal obliteration, left gastric artery embolization, and partial splenic artery embolization were introduced, improving the survival of patients with bleeding EVs. In the 1980s, endoscopic treatment, endoscopic injection sclerotherapy (EIS), and endoscopic variceal ligation (EVL), further contributed to improved survival. We combined IVR with endoscopic treatment or EIS with EVL. Most patients with EVs treated endoscopically required follow- up treatment for recurrent varices. Proper management of recurrent EVs can significantly improve patients’ quality of life. Recently, we have performed EVL at 2-mo (bimonthly) intervals for the management of EVs. Longer intervals between treatment sessions resulted in a higher rate of total eradication and lower rates of recurrence and additional treatment.展开更多
Bleeding from gastric varices has been successfully treated by endoscopic modalities. Once the bleeding from the gastric varices is stabilized, endoscopic treatment and/or interventional radiology should be performed ...Bleeding from gastric varices has been successfully treated by endoscopic modalities. Once the bleeding from the gastric varices is stabilized, endoscopic treatment and/or interventional radiology should be performed to eradicate varices completely. Partial splenic artery embolization is a supplemental treatment to prolong the obliteration of the veins feeding and/or draining the varices. The overall incidence of bleeding from gastric varices is lower than that from esophageal varices. No studies to date have defi nitively characterized the causal factors behind bleeding from gastric varices. The initial episodes of bleeding from esophageal varices or gastric varices without prior treatment may be at least partly triggered by a violation of the mucosal barrier overlying varices. This is especially likely in the case of varices of the fundus. In view of the high rate of hemostasis achieved among bleeding gastric varices, treatment should be administered in selective cases. Among untreated cases, steps to prevent gastric mucosal injury confer very important protection against gastric variceal bleeding.展开更多
Splenic arteriovenous fistulas(SAVFs) with splenic vein aneurysms are extremely rare entities. There have been no prior reports of SAVFs developing after laparoscopic pancreatectomy. Here, we report the first case. A ...Splenic arteriovenous fistulas(SAVFs) with splenic vein aneurysms are extremely rare entities. There have been no prior reports of SAVFs developing after laparoscopic pancreatectomy. Here, we report the first case. A 40-year-old man underwent a laparoscopic, spleen-preserving, distal pancreatectomy for an endocrine neoplasm of the pancreatic tail. Three months after surgery, a computed tomography(CT) scan demonstrated an SAVF with a dilated splenic vein. The SAVF, together with the splenic vein aneurysm, was successfully treated using percutaneous transarterial coil embolization of the splenic artery, including the SAVF and drainage vein. After the endovascular treatment, the patient's recovery was uneventful. He was discharged on postoperative day 6 and continues to be well 3 mo after discharge. An abdominal CT scan performed at his 3-mo follow-up demonstrated complete thrombosis of the splenic vein aneurysm, which had decreased to a 40 mm diameter. This is the first reported case of SAVF following a laparoscopic pancreatectomy and demonstrates the usefulness of endovascular treatment for this type of complication.展开更多
Cholangiocarcinoma is the second most common primary hepatic cancer. Despite advances in diagnostic techniques during the past decade, cholangiocarcinoma is usually encountered at an advanced stage. In this review, we...Cholangiocarcinoma is the second most common primary hepatic cancer. Despite advances in diagnostic techniques during the past decade, cholangiocarcinoma is usually encountered at an advanced stage. In this review, we describe the classification, diagnosis, and initial management of cholangiocarcinoma with obstructive jaundice.展开更多
The patient was a 30-year-old female who had undergone excision of the extrahepatic bile duct and Rouxen-Y hepaticojejunostomy for congenital biliary dilatation at the age of 7.Thereafter,she suffered from recurrent a...The patient was a 30-year-old female who had undergone excision of the extrahepatic bile duct and Rouxen-Y hepaticojejunostomy for congenital biliary dilatation at the age of 7.Thereafter,she suffered from recurrent acute pancreatitis due to pancreaticobiliary maljunction and received subtotal stomach-preserving pancreaticoduodenectomy.She developed a pancreatic fistula and an intra-abdominal abscess after the operation.These complications were improved by percutaneous abscess drainage and antibiotic therapy.How ever,upper abdominal discomfort and the elevation of serum pancreatic enzymes persisted due to stenosis from the pancreaticojejunostomy.Because we could not accomplish dilation of the stenosis by endoscopic retrograde cholangiopancreatography,we tried an endoscopic ultrasonography(EUS) guided rendezvous technique for pancreatic duct drainage.After transgastric puncture of the pancreatic duct using an EUS-fine needle aspiration needle,the guidewire was inserted into the pancreatic duct and finally reached to the jejunum through the stenotic anastomosis.We changed the echoendoscope to an oblique-viewing endoscope,then grasped the guidewire and withdrew it through the scope.The stenosis of the pancreaticojejunostomy was dilated up to 4 mm,and a pancreatic stent was put in place.Though the pancreatic stent was removed after three months,the patient remained symptomfree.Pancreatic duct drainage using an EUS-guided rendezvous technique was useful for the treatment of a stenotic pancreaticojejunostomy after pancreaticoduodenectomy.展开更多
Lymph node (LN) metastases from hepatocellular carcinoma (HCC) are considered uncommon. We describe the surgical resection of a solitary para-aortic LN metastasis from HCC. A 65-year-old Japanese man with B-type liver...Lymph node (LN) metastases from hepatocellular carcinoma (HCC) are considered uncommon. We describe the surgical resection of a solitary para-aortic LN metastasis from HCC. A 65-year-old Japanese man with B-type liver cirrhosis was admitted for the evaluation of a liver tumor. He had already undergone radiofrequency ablation, transcatheter arterial chemoembolization, and percutaneous ethanol injection therapy for HCC. Despite treatment, viable regions remained in segments 4 and 8. We performed a right paramedian sectionectomy with partial resection of the left paramedian section of the liver. Six months later, serum concentrations of alpha-fetoprotein (189 ng/mL) and PIVKA-2 (507 mAU/mL) increased. Enhanced com- puted tomography of the abdomen revealed a tumor (20 mm in diameter) on the right side of the abdominal aorta. Fluorine-18 fluorodeoxyglucose positron emission tomography revealed an increased standard uptake value. There was no evidence of recurrence in other regions. Esophagogastroduodenoscopy and colonoscopy revealed no malignant tumor in the gastrointestinal tract. Para-aortic LN metastasis from HCC was thus diagnosed. We performed lymphadenectomy. Histopathological examination revealed that the tumor was largely necrotic, with poorly differentiated HCC on its surface, which confirmed the suspected diagnosis. After 6 mo tumor marker levels were normal, with no evidence of recurrence. Our experience suggests that a solitary para-aortic LN metastasis from HCC can be treated surgically.展开更多
Tremendous advances in artificial intelligence(AI)in medical image analysis have been achieved in recent years.The integration of AI is expected to cause a revolution in various areas of medicine,including gastrointes...Tremendous advances in artificial intelligence(AI)in medical image analysis have been achieved in recent years.The integration of AI is expected to cause a revolution in various areas of medicine,including gastrointestinal(GI)pathology.Currently,deep learning algorithms have shown promising benefits in areas of diagnostic histopathology,such as tumor identification,classification,prognosis prediction,and biomarker/genetic alteration prediction.While AI cannot substitute pathologists,carefully constructed AI applications may increase workforce productivity and diagnostic accuracy in pathology practice.Regardless of these promising advances,unlike the areas of radiology or cardiology imaging,no histopathology-based AI application has been approved by a regulatory authority or for public reimbursement.Thus,implying that there are still some obstacles to be overcome before AI applications can be safely and effectively implemented in real-life pathology practice.The challenges have been identified at different stages of the development process,such as needs identification,data curation,model development,validation,regulation,modification of daily workflow,and cost-effectiveness balance.The aim of this review is to present challenges in the process of AI development,validation,and regulation that should be overcome for its implementation in real-life GI pathology practice.展开更多
AIM: To elucidate the biological effects of transforming growth factor-β1 (TGF-β1) on intrahepatic cholan- giocarcinoma (ICC). METHODS: We investigated the effects of TGF-β1 on human ICC cell lines (HuCCT1, MEC, an...AIM: To elucidate the biological effects of transforming growth factor-β1 (TGF-β1) on intrahepatic cholan- giocarcinoma (ICC). METHODS: We investigated the effects of TGF-β1 on human ICC cell lines (HuCCT1, MEC, and HuH-28) by monitoring the influence of TGF-β1 on tumor growth and interleukin-6 (IL-6) expression in ICC cells. RESULTS: All three human ICC cell lines produced TGF-β1 and demonstrated accelerated growth in the presence of TGF-β1 with no apoptotic effect. Studies on HuCCT1 revealed a TGF-β1-induced stimulation of the expression of TGF-β1, as well as a decrease in TGF-β1 mRNA expression induced by neutralizing anti-TGF-β1 antibody. These results indicate that TGF-β1 stimulates the production and function of TGF-β1 in an autocrine fashion. Further, IL-6 secretion was observed in all three cell lines and exhibited an inhibitory response to neutralizing anti-TGF-β1 antibody. Experiments using HuCCT1 revealed a TGF-β1-induced acceleration of IL-6 protein expression and mRNA levels. These findings demonstrate a functional interaction between TGF-β1 and IL-6. All three cell lines proliferated in the presence of IL-6. In contrast, TGF-β1 induced no growth effect in HuCCT1 in the presence of small interfering RNA against a specific cell surface receptor of IL-6 and signal transducer and activator of transcription-3. CONCLUSION: ICC cells produce TGF-β1 and confer a TGF-β1-induced growth effect in an autocrine fashion.TGF-β1 activates IL-6 production, and the functional interaction between TGF-β1 and IL-6 contributes to ICC cell growth by TGF-β1.展开更多
This report describes a method for percutaneous transhepatic biliary stenting with a BLAKE Silicone Drain, and discusses the usefulness of placement of the drain connected to a J-VAC Suction Reservoir for the treatmen...This report describes a method for percutaneous transhepatic biliary stenting with a BLAKE Silicone Drain, and discusses the usefulness of placement of the drain connected to a J-VAC Suction Reservoir for the treatment of stenotic hepaticojejunostomy. Percutaneous transhepatic biliary drainage was performed under ultrasonographic guidance in a patient with stenotic hepaticojejunostomy after hepatectomy for hepatic hilum malignancy. The technique used was as follows. After dilatation of the drainage root, an 11-Fr tube with several side holes was passed through the stenosis of the hepaticojejunostomy. A 10-Fr BLAKE Silicone Drain is · exible, which precludes one-step insertion. One week after insertion of the 11-Fr tube, a 0.035-inch guidewire was inserted into the tube. After removal of the 11-Fr tube, the guidewire was put into the channel of a 10-Fr BLAKE Silicone Drain. The drain was inserted into the jejunal limb through the intrahepatic bile duct and was connected to a J-VAC Suction Reservoir. Low-pressure continued suction was applied. Patients can be discharged after insertion of the 10-Fr BLAKE Silicone Drain connected to the J-VAC Suction Reservoir. Placement of a percutaneous transhepatic biliary stent using a 10-Fr BLAKE Silicone Drain connected to a J-VAC Suction Reservoir is useful for the treatment of stenotic hepaticojejunostomy.展开更多
BACKGROUND The incidence of internal hernias has recently increased in concordance with the popularization of laparoscopic surgery.Of particular concern are internal hernias occurring in Petersen's space,a space t...BACKGROUND The incidence of internal hernias has recently increased in concordance with the popularization of laparoscopic surgery.Of particular concern are internal hernias occurring in Petersen's space,a space that is surgically created after treatment for gastric cancer and obesity.These hernias cause devastating sequelae,such as massive intestinal necrosis,fatal Roux limb necrosis,and superior mesenteric vein thrombus.In addition,protein-losing enteropathy(PLE)is a rare syndrome involving gastrointestinal protein loss,although its relationship with internal Petersen’s hernias remains unknown.CASE SUMMARY A 75-year-old man with a history of laparotomy for early gastric cancer developed Petersen's hernia 1 year and 5 mo after surgery.He was successfully treated by reducing the incarcerated small intestine and closure of Petersen’s defect without resection of the small intestine.Approximately 3 mo after his surgery for Petersen’s hernia,he developed bilateral leg edema and hypoalbuminemia.He was diagnosed with PLE with an alpha-1 antitrypsin clearance of 733 mL/24 h.Double-balloon enteroscopy revealed extensive jejunal ulceration as the etiology,and it facilitated minimum bowel resection.Pathological analysis showed extensive jejunal ulceration and collagen hyperplasia with nonspecific inflammation of all layers without lymphangiectasia,lymphoma,or vascular abnormalities.His postoperative course was unremarkable,and his bilateral leg edema and hypoalbuminemia improved after 1 mo.There was no relapse over the 5-year follow-up period.CONCLUSION PLE and extensive jejunal ulceration may occur after Petersen's hernia.Doubleballoon enteroscopy helps identify and resect these lesions.展开更多
Endometrial cancer is the most common gynecological cancer in developed countries,and its incidence has increased.The majority of patients with endometrial cancer have an early disease and favorable prognosis;however,...Endometrial cancer is the most common gynecological cancer in developed countries,and its incidence has increased.The majority of patients with endometrial cancer have an early disease and favorable prognosis;however,a significant proportion of endometrial cancer,which mainly comprises high-grade or type II endometrial cancer such as serous,clear cell,and carcinosarcoma,shows advanced/recurrent disease and dismal prognosis.Novel therapeutic development is required for patients with aggressive endometrial cancers.Recent genomic and immunohistochemical analyses revealed human epidermal growth factor receptor 2(HER2)overexpression/gene amplification in 20%-40%of patients with type II endometrial cancer.Historically,HER2 targeted therapy has been developed for various major cancers,including breast and gastric cancer.Notably,recent advances in HER2 targeted therapy for patients with type II endometrial cancer are also expected to change.Simultaneously,an optimized HER2 test for endometrial cancer as companion diagnostics should be established.In this review,we summarize the recent findings on endometrial cancer,current treatment,optimized HER2 testing,key clinical trials on HER2 targeted therapy,and future directions in aggressive endometrial cancer,including serous carcinoma and carcinosarcoma.展开更多
The aim of the present study was to investigate the efficacy of the actual consuming n-3 PUFA for remission-maintenance in IBD patients. A questionnaire on the dietary habits of patients one month before hospitalizati...The aim of the present study was to investigate the efficacy of the actual consuming n-3 PUFA for remission-maintenance in IBD patients. A questionnaire on the dietary habits of patients one month before hospitalization (Q1) was completed by 24 patients with IBD (10 ulcerative colitis (UC) subjects and 14 Crohn’s disease (CD) subjects) treated at our hospital. We educated the study subjects about an n-3 PUFA diet, and a follow-up survey (Q2) was conducted 6 to 12 months after discharge. Disease activity was evaluated using the International Organization for the Study of Inflammatory Bowel Disease (IOIBD) score and/or the Crohn’s Disease Activity Index (CDAI) score for CD and the partial UCDAI score without endoscopic evaluation for UC. Q1 showed that the average n-3 and n-6 PUFA intakes were 1673 ± 1651 mg and 9146 ± 5217 mg, respectively, and the average n-3/n-6 ratio was 0.27 ± 0.31. In Q2, the intake of n-3 PUFA was significantly higher (3671 ± 1684 mg, p < 0.001), whereas the n-6 PUFA intake decreased significantly (5217 ± 1973 mg, p < 0.001) compared to those in Q1. As a consequence, the dietary n-3/ n-6 ratio was significantly increased (0.87 ± 0.60, p < 0.001). Maintenance of the remission rate was significantly higher in IBD patients who complied with the n-3 diet, and these patients maintained a dietary n-3/n-6 ratio of 0.432 or higher (17 of 23 cases;70.8%, p < 0.03) compared to that observed for IBD patients who did not comply with the diet. These results emphasize the importance of adjusting dietary PUFA and suggest that the n-3 diet may be effective in maintaining the remission of IBD.展开更多
Carcinosarcomas are rare,malignant,biphasic tumors simultaneously comprising carcinoma and sarcoma in a single tumor.We present an extremely rare case of gastric carcinosarcoma with an osteoblastic component that dras...Carcinosarcomas are rare,malignant,biphasic tumors simultaneously comprising carcinoma and sarcoma in a single tumor.We present an extremely rare case of gastric carcinosarcoma with an osteoblastic component that drastically changed its shape within 2 mo.A 59-year-old male patient presented to the emergency outpatient unit with a complaint of black stool.Gastrointestinal endoscopy showed an ulcerated mass in the cardia of the lesser curvature of the stomach.Biopsy specimens revealed only adenocarcinoma.Two months later,the ulcerated lesion drastically changed its shape into an exophytic tumor.Total gastrectomy was performed.In the resected specimen,the gastric tumor contained both adenocarcinoma and sarcoma components with lace-like osteoid.The patient died 7 mo after the operation,and an autopsy was performed.In the autopsy,widespread metastases were present in the liver,lung,lymph nodes and peritoneum.In this report,we describe a case of gastric carcinosarcoma and presume its tumorigenesis based on the autopsy findings.展开更多
BACKGROUND Acute portal vein thrombosis(PVT)with bowel necrosis is a fatal condition with a 50%-75%mortality rate.This report describes the successful endovascular treatment(EVT)of two patients with severe PVT.CASE SU...BACKGROUND Acute portal vein thrombosis(PVT)with bowel necrosis is a fatal condition with a 50%-75%mortality rate.This report describes the successful endovascular treatment(EVT)of two patients with severe PVT.CASE SUMMARY The first patient was a 22-year-old man who presented with abdominal pain lasting 3 d.The second patient was a 48-year-old man who presented with acute abdominal pain.Following contrast-enhanced computed tomography,both patients were diagnosed with massive PVT extending to the splenic and superior mesenteric veins.Hybrid treatment(simultaneous necrotic bowel resection and EVT)was performed in a hybrid operating room(OR).EVTs,including aspiration thrombectomy,catheter-directed thrombolysis(CDT),and continuous CDT,were performed via the ileocolic vein under laparotomy.The portal veins were patent 4 and 6 mo posttreatment in the 22-year-old and 48-year-old patients,respectively.CONCLUSION Hybrid necrotic bowel resection and transileocolic EVT performed in a hybrid OR is effective and safe.展开更多
BACKGROUND Digital pathology image(DPI)analysis has been developed by machine learning(ML)techniques.However,little attention has been paid to the reproducibility of ML-based histological classification in heterochron...BACKGROUND Digital pathology image(DPI)analysis has been developed by machine learning(ML)techniques.However,little attention has been paid to the reproducibility of ML-based histological classification in heterochronously obtained DPIs of the same hematoxylin and eosin(HE)slide.AIM To elucidate the frequency and preventable causes of discordant classification results of DPI analysis using ML for the heterochronously obtained DPIs.METHODS We created paired DPIs by scanning 298 HE stained slides containing 584 tissues twice with a virtual slide scanner.The paired DPIs were analyzed by our MLaided classification model.We defined non-flipped and flipped groups as the paired DPIs with concordant and discordant classification results,respectively.We compared differences in color and blur between the non-flipped and flipped groups by L1-norm and a blur index,respectively.RESULTS We observed discordant classification results in 23.1%of the paired DPIs obtained by two independent scans of the same microscope slide.We detected no significant difference in the L1-norm of each color channel between the two groups;however,the flipped group showed a significantly higher blur index than the non-flipped group.CONCLUSION Our results suggest that differences in the blur-not the color-of the paired DPIs may cause discordant classification results.An ML-aided classification model for DPI should be tested for this potential cause of the reduced reproducibility of the model.In a future study,a slide scanner and/or a preprocessing method of minimizing DPI blur should be developed.展开更多
Aim:The present study was designed to evaluate the feasibility of preoperative liver functional volumetry performed by 3D-technetium-99m-diethylenetriaminepentaacetic acid-galactosyl-human serum albumin(99mTc-GSA)scin...Aim:The present study was designed to evaluate the feasibility of preoperative liver functional volumetry performed by 3D-technetium-99m-diethylenetriaminepentaacetic acid-galactosyl-human serum albumin(99mTc-GSA)scintigraphy/vascular fusion imaging using SYNAPSE VINCENT and to examine the discrepancy between conventional and functional volumetry.Methods:The study group comprised 15 patients who underwent preoperative 3-dimensional(3D)-99mTc-GSA scintigraphy/vascular fusion imaging using SYNAPSE VINCENT software before hepatectomy between July 2014 and August 2015.The diagnosis was hepatocellular carcinoma(n=4),metastatic liver tumor(n=10),or intrahepatic cholangiocarcinoma(n=1).Right hepatectomy was performed in 2 patients,left hepatectomy in 3 patients,right posterior sectionectomy in 3 patients,segmentectomy in 2 patients,and partial hepatectomy in 4 patients.99mTc-GSA scintigraphy and computed tomography(CT)were performed to construct 3D-99mTc-GSA scintigraphy/vascular fused images.The conventional volume ratio of the planned resection region without tumor(%CT),and the functional volume ratio of the planned resection region without tumor(%GSA)were calculated.The discrepancy ratio was calculated as follows:discrepancy ratio=100-%GSA/%CT×100(%).Results:The%GSA(17.9±16.7%)was significantly lower than the%CT(21.5±17.6%)(P<0.036).In all except 2 patients,the%GSA was lower than the%CT.The discrepancy ratio ranged from-4%to 75%(median,20.7%).Conclusion:3D-99mTc-GSA scintigraphy/vascular fused images constructed using SYNAPSE VINCENT were useful for noninvasively performing functional liver volumetry in patients scheduled to undergo various patterns of hepatectomy.In planned resection regions without tumor,the functional volume ratio was about 20%lower than the conventional volume ratio.展开更多
文摘Bleeding from esophageal varices (EVs) is a catastrophic complication of chronic liver disease. Many years ago, surgical procedures such as esophageal transection or distal splenorenal shunting were the only treatments for EVs. In the 1970s, interventional radiology procedures such as transportal obliteration, left gastric artery embolization, and partial splenic artery embolization were introduced, improving the survival of patients with bleeding EVs. In the 1980s, endoscopic treatment, endoscopic injection sclerotherapy (EIS), and endoscopic variceal ligation (EVL), further contributed to improved survival. We combined IVR with endoscopic treatment or EIS with EVL. Most patients with EVs treated endoscopically required follow- up treatment for recurrent varices. Proper management of recurrent EVs can significantly improve patients’ quality of life. Recently, we have performed EVL at 2-mo (bimonthly) intervals for the management of EVs. Longer intervals between treatment sessions resulted in a higher rate of total eradication and lower rates of recurrence and additional treatment.
文摘Bleeding from gastric varices has been successfully treated by endoscopic modalities. Once the bleeding from the gastric varices is stabilized, endoscopic treatment and/or interventional radiology should be performed to eradicate varices completely. Partial splenic artery embolization is a supplemental treatment to prolong the obliteration of the veins feeding and/or draining the varices. The overall incidence of bleeding from gastric varices is lower than that from esophageal varices. No studies to date have defi nitively characterized the causal factors behind bleeding from gastric varices. The initial episodes of bleeding from esophageal varices or gastric varices without prior treatment may be at least partly triggered by a violation of the mucosal barrier overlying varices. This is especially likely in the case of varices of the fundus. In view of the high rate of hemostasis achieved among bleeding gastric varices, treatment should be administered in selective cases. Among untreated cases, steps to prevent gastric mucosal injury confer very important protection against gastric variceal bleeding.
文摘Splenic arteriovenous fistulas(SAVFs) with splenic vein aneurysms are extremely rare entities. There have been no prior reports of SAVFs developing after laparoscopic pancreatectomy. Here, we report the first case. A 40-year-old man underwent a laparoscopic, spleen-preserving, distal pancreatectomy for an endocrine neoplasm of the pancreatic tail. Three months after surgery, a computed tomography(CT) scan demonstrated an SAVF with a dilated splenic vein. The SAVF, together with the splenic vein aneurysm, was successfully treated using percutaneous transarterial coil embolization of the splenic artery, including the SAVF and drainage vein. After the endovascular treatment, the patient's recovery was uneventful. He was discharged on postoperative day 6 and continues to be well 3 mo after discharge. An abdominal CT scan performed at his 3-mo follow-up demonstrated complete thrombosis of the splenic vein aneurysm, which had decreased to a 40 mm diameter. This is the first reported case of SAVF following a laparoscopic pancreatectomy and demonstrates the usefulness of endovascular treatment for this type of complication.
文摘Cholangiocarcinoma is the second most common primary hepatic cancer. Despite advances in diagnostic techniques during the past decade, cholangiocarcinoma is usually encountered at an advanced stage. In this review, we describe the classification, diagnosis, and initial management of cholangiocarcinoma with obstructive jaundice.
基金Supported by Grant-in-Aid to the Research Committee of the Intractable Pancreatic Diseases(Chairman,Shimosegawa T),provided from the Ministry of Health,Labour and Welfare of Japan
文摘The patient was a 30-year-old female who had undergone excision of the extrahepatic bile duct and Rouxen-Y hepaticojejunostomy for congenital biliary dilatation at the age of 7.Thereafter,she suffered from recurrent acute pancreatitis due to pancreaticobiliary maljunction and received subtotal stomach-preserving pancreaticoduodenectomy.She developed a pancreatic fistula and an intra-abdominal abscess after the operation.These complications were improved by percutaneous abscess drainage and antibiotic therapy.How ever,upper abdominal discomfort and the elevation of serum pancreatic enzymes persisted due to stenosis from the pancreaticojejunostomy.Because we could not accomplish dilation of the stenosis by endoscopic retrograde cholangiopancreatography,we tried an endoscopic ultrasonography(EUS) guided rendezvous technique for pancreatic duct drainage.After transgastric puncture of the pancreatic duct using an EUS-fine needle aspiration needle,the guidewire was inserted into the pancreatic duct and finally reached to the jejunum through the stenotic anastomosis.We changed the echoendoscope to an oblique-viewing endoscope,then grasped the guidewire and withdrew it through the scope.The stenosis of the pancreaticojejunostomy was dilated up to 4 mm,and a pancreatic stent was put in place.Though the pancreatic stent was removed after three months,the patient remained symptomfree.Pancreatic duct drainage using an EUS-guided rendezvous technique was useful for the treatment of a stenotic pancreaticojejunostomy after pancreaticoduodenectomy.
文摘Lymph node (LN) metastases from hepatocellular carcinoma (HCC) are considered uncommon. We describe the surgical resection of a solitary para-aortic LN metastasis from HCC. A 65-year-old Japanese man with B-type liver cirrhosis was admitted for the evaluation of a liver tumor. He had already undergone radiofrequency ablation, transcatheter arterial chemoembolization, and percutaneous ethanol injection therapy for HCC. Despite treatment, viable regions remained in segments 4 and 8. We performed a right paramedian sectionectomy with partial resection of the left paramedian section of the liver. Six months later, serum concentrations of alpha-fetoprotein (189 ng/mL) and PIVKA-2 (507 mAU/mL) increased. Enhanced com- puted tomography of the abdomen revealed a tumor (20 mm in diameter) on the right side of the abdominal aorta. Fluorine-18 fluorodeoxyglucose positron emission tomography revealed an increased standard uptake value. There was no evidence of recurrence in other regions. Esophagogastroduodenoscopy and colonoscopy revealed no malignant tumor in the gastrointestinal tract. Para-aortic LN metastasis from HCC was thus diagnosed. We performed lymphadenectomy. Histopathological examination revealed that the tumor was largely necrotic, with poorly differentiated HCC on its surface, which confirmed the suspected diagnosis. After 6 mo tumor marker levels were normal, with no evidence of recurrence. Our experience suggests that a solitary para-aortic LN metastasis from HCC can be treated surgically.
文摘Tremendous advances in artificial intelligence(AI)in medical image analysis have been achieved in recent years.The integration of AI is expected to cause a revolution in various areas of medicine,including gastrointestinal(GI)pathology.Currently,deep learning algorithms have shown promising benefits in areas of diagnostic histopathology,such as tumor identification,classification,prognosis prediction,and biomarker/genetic alteration prediction.While AI cannot substitute pathologists,carefully constructed AI applications may increase workforce productivity and diagnostic accuracy in pathology practice.Regardless of these promising advances,unlike the areas of radiology or cardiology imaging,no histopathology-based AI application has been approved by a regulatory authority or for public reimbursement.Thus,implying that there are still some obstacles to be overcome before AI applications can be safely and effectively implemented in real-life pathology practice.The challenges have been identified at different stages of the development process,such as needs identification,data curation,model development,validation,regulation,modification of daily workflow,and cost-effectiveness balance.The aim of this review is to present challenges in the process of AI development,validation,and regulation that should be overcome for its implementation in real-life GI pathology practice.
基金Supported by the Ministry of Education, Science, Sports, and Culture of Japan, through a Grant-in-Aid for Scientific Research (C)
文摘AIM: To elucidate the biological effects of transforming growth factor-β1 (TGF-β1) on intrahepatic cholan- giocarcinoma (ICC). METHODS: We investigated the effects of TGF-β1 on human ICC cell lines (HuCCT1, MEC, and HuH-28) by monitoring the influence of TGF-β1 on tumor growth and interleukin-6 (IL-6) expression in ICC cells. RESULTS: All three human ICC cell lines produced TGF-β1 and demonstrated accelerated growth in the presence of TGF-β1 with no apoptotic effect. Studies on HuCCT1 revealed a TGF-β1-induced stimulation of the expression of TGF-β1, as well as a decrease in TGF-β1 mRNA expression induced by neutralizing anti-TGF-β1 antibody. These results indicate that TGF-β1 stimulates the production and function of TGF-β1 in an autocrine fashion. Further, IL-6 secretion was observed in all three cell lines and exhibited an inhibitory response to neutralizing anti-TGF-β1 antibody. Experiments using HuCCT1 revealed a TGF-β1-induced acceleration of IL-6 protein expression and mRNA levels. These findings demonstrate a functional interaction between TGF-β1 and IL-6. All three cell lines proliferated in the presence of IL-6. In contrast, TGF-β1 induced no growth effect in HuCCT1 in the presence of small interfering RNA against a specific cell surface receptor of IL-6 and signal transducer and activator of transcription-3. CONCLUSION: ICC cells produce TGF-β1 and confer a TGF-β1-induced growth effect in an autocrine fashion.TGF-β1 activates IL-6 production, and the functional interaction between TGF-β1 and IL-6 contributes to ICC cell growth by TGF-β1.
文摘This report describes a method for percutaneous transhepatic biliary stenting with a BLAKE Silicone Drain, and discusses the usefulness of placement of the drain connected to a J-VAC Suction Reservoir for the treatment of stenotic hepaticojejunostomy. Percutaneous transhepatic biliary drainage was performed under ultrasonographic guidance in a patient with stenotic hepaticojejunostomy after hepatectomy for hepatic hilum malignancy. The technique used was as follows. After dilatation of the drainage root, an 11-Fr tube with several side holes was passed through the stenosis of the hepaticojejunostomy. A 10-Fr BLAKE Silicone Drain is · exible, which precludes one-step insertion. One week after insertion of the 11-Fr tube, a 0.035-inch guidewire was inserted into the tube. After removal of the 11-Fr tube, the guidewire was put into the channel of a 10-Fr BLAKE Silicone Drain. The drain was inserted into the jejunal limb through the intrahepatic bile duct and was connected to a J-VAC Suction Reservoir. Low-pressure continued suction was applied. Patients can be discharged after insertion of the 10-Fr BLAKE Silicone Drain connected to the J-VAC Suction Reservoir. Placement of a percutaneous transhepatic biliary stent using a 10-Fr BLAKE Silicone Drain connected to a J-VAC Suction Reservoir is useful for the treatment of stenotic hepaticojejunostomy.
文摘BACKGROUND The incidence of internal hernias has recently increased in concordance with the popularization of laparoscopic surgery.Of particular concern are internal hernias occurring in Petersen's space,a space that is surgically created after treatment for gastric cancer and obesity.These hernias cause devastating sequelae,such as massive intestinal necrosis,fatal Roux limb necrosis,and superior mesenteric vein thrombus.In addition,protein-losing enteropathy(PLE)is a rare syndrome involving gastrointestinal protein loss,although its relationship with internal Petersen’s hernias remains unknown.CASE SUMMARY A 75-year-old man with a history of laparotomy for early gastric cancer developed Petersen's hernia 1 year and 5 mo after surgery.He was successfully treated by reducing the incarcerated small intestine and closure of Petersen’s defect without resection of the small intestine.Approximately 3 mo after his surgery for Petersen’s hernia,he developed bilateral leg edema and hypoalbuminemia.He was diagnosed with PLE with an alpha-1 antitrypsin clearance of 733 mL/24 h.Double-balloon enteroscopy revealed extensive jejunal ulceration as the etiology,and it facilitated minimum bowel resection.Pathological analysis showed extensive jejunal ulceration and collagen hyperplasia with nonspecific inflammation of all layers without lymphangiectasia,lymphoma,or vascular abnormalities.His postoperative course was unremarkable,and his bilateral leg edema and hypoalbuminemia improved after 1 mo.There was no relapse over the 5-year follow-up period.CONCLUSION PLE and extensive jejunal ulceration may occur after Petersen's hernia.Doubleballoon enteroscopy helps identify and resect these lesions.
文摘Endometrial cancer is the most common gynecological cancer in developed countries,and its incidence has increased.The majority of patients with endometrial cancer have an early disease and favorable prognosis;however,a significant proportion of endometrial cancer,which mainly comprises high-grade or type II endometrial cancer such as serous,clear cell,and carcinosarcoma,shows advanced/recurrent disease and dismal prognosis.Novel therapeutic development is required for patients with aggressive endometrial cancers.Recent genomic and immunohistochemical analyses revealed human epidermal growth factor receptor 2(HER2)overexpression/gene amplification in 20%-40%of patients with type II endometrial cancer.Historically,HER2 targeted therapy has been developed for various major cancers,including breast and gastric cancer.Notably,recent advances in HER2 targeted therapy for patients with type II endometrial cancer are also expected to change.Simultaneously,an optimized HER2 test for endometrial cancer as companion diagnostics should be established.In this review,we summarize the recent findings on endometrial cancer,current treatment,optimized HER2 testing,key clinical trials on HER2 targeted therapy,and future directions in aggressive endometrial cancer,including serous carcinoma and carcinosarcoma.
文摘The aim of the present study was to investigate the efficacy of the actual consuming n-3 PUFA for remission-maintenance in IBD patients. A questionnaire on the dietary habits of patients one month before hospitalization (Q1) was completed by 24 patients with IBD (10 ulcerative colitis (UC) subjects and 14 Crohn’s disease (CD) subjects) treated at our hospital. We educated the study subjects about an n-3 PUFA diet, and a follow-up survey (Q2) was conducted 6 to 12 months after discharge. Disease activity was evaluated using the International Organization for the Study of Inflammatory Bowel Disease (IOIBD) score and/or the Crohn’s Disease Activity Index (CDAI) score for CD and the partial UCDAI score without endoscopic evaluation for UC. Q1 showed that the average n-3 and n-6 PUFA intakes were 1673 ± 1651 mg and 9146 ± 5217 mg, respectively, and the average n-3/n-6 ratio was 0.27 ± 0.31. In Q2, the intake of n-3 PUFA was significantly higher (3671 ± 1684 mg, p < 0.001), whereas the n-6 PUFA intake decreased significantly (5217 ± 1973 mg, p < 0.001) compared to those in Q1. As a consequence, the dietary n-3/ n-6 ratio was significantly increased (0.87 ± 0.60, p < 0.001). Maintenance of the remission rate was significantly higher in IBD patients who complied with the n-3 diet, and these patients maintained a dietary n-3/n-6 ratio of 0.432 or higher (17 of 23 cases;70.8%, p < 0.03) compared to that observed for IBD patients who did not comply with the diet. These results emphasize the importance of adjusting dietary PUFA and suggest that the n-3 diet may be effective in maintaining the remission of IBD.
文摘Carcinosarcomas are rare,malignant,biphasic tumors simultaneously comprising carcinoma and sarcoma in a single tumor.We present an extremely rare case of gastric carcinosarcoma with an osteoblastic component that drastically changed its shape within 2 mo.A 59-year-old male patient presented to the emergency outpatient unit with a complaint of black stool.Gastrointestinal endoscopy showed an ulcerated mass in the cardia of the lesser curvature of the stomach.Biopsy specimens revealed only adenocarcinoma.Two months later,the ulcerated lesion drastically changed its shape into an exophytic tumor.Total gastrectomy was performed.In the resected specimen,the gastric tumor contained both adenocarcinoma and sarcoma components with lace-like osteoid.The patient died 7 mo after the operation,and an autopsy was performed.In the autopsy,widespread metastases were present in the liver,lung,lymph nodes and peritoneum.In this report,we describe a case of gastric carcinosarcoma and presume its tumorigenesis based on the autopsy findings.
文摘BACKGROUND Acute portal vein thrombosis(PVT)with bowel necrosis is a fatal condition with a 50%-75%mortality rate.This report describes the successful endovascular treatment(EVT)of two patients with severe PVT.CASE SUMMARY The first patient was a 22-year-old man who presented with abdominal pain lasting 3 d.The second patient was a 48-year-old man who presented with acute abdominal pain.Following contrast-enhanced computed tomography,both patients were diagnosed with massive PVT extending to the splenic and superior mesenteric veins.Hybrid treatment(simultaneous necrotic bowel resection and EVT)was performed in a hybrid operating room(OR).EVTs,including aspiration thrombectomy,catheter-directed thrombolysis(CDT),and continuous CDT,were performed via the ileocolic vein under laparotomy.The portal veins were patent 4 and 6 mo posttreatment in the 22-year-old and 48-year-old patients,respectively.CONCLUSION Hybrid necrotic bowel resection and transileocolic EVT performed in a hybrid OR is effective and safe.
文摘BACKGROUND Digital pathology image(DPI)analysis has been developed by machine learning(ML)techniques.However,little attention has been paid to the reproducibility of ML-based histological classification in heterochronously obtained DPIs of the same hematoxylin and eosin(HE)slide.AIM To elucidate the frequency and preventable causes of discordant classification results of DPI analysis using ML for the heterochronously obtained DPIs.METHODS We created paired DPIs by scanning 298 HE stained slides containing 584 tissues twice with a virtual slide scanner.The paired DPIs were analyzed by our MLaided classification model.We defined non-flipped and flipped groups as the paired DPIs with concordant and discordant classification results,respectively.We compared differences in color and blur between the non-flipped and flipped groups by L1-norm and a blur index,respectively.RESULTS We observed discordant classification results in 23.1%of the paired DPIs obtained by two independent scans of the same microscope slide.We detected no significant difference in the L1-norm of each color channel between the two groups;however,the flipped group showed a significantly higher blur index than the non-flipped group.CONCLUSION Our results suggest that differences in the blur-not the color-of the paired DPIs may cause discordant classification results.An ML-aided classification model for DPI should be tested for this potential cause of the reduced reproducibility of the model.In a future study,a slide scanner and/or a preprocessing method of minimizing DPI blur should be developed.
文摘Aim:The present study was designed to evaluate the feasibility of preoperative liver functional volumetry performed by 3D-technetium-99m-diethylenetriaminepentaacetic acid-galactosyl-human serum albumin(99mTc-GSA)scintigraphy/vascular fusion imaging using SYNAPSE VINCENT and to examine the discrepancy between conventional and functional volumetry.Methods:The study group comprised 15 patients who underwent preoperative 3-dimensional(3D)-99mTc-GSA scintigraphy/vascular fusion imaging using SYNAPSE VINCENT software before hepatectomy between July 2014 and August 2015.The diagnosis was hepatocellular carcinoma(n=4),metastatic liver tumor(n=10),or intrahepatic cholangiocarcinoma(n=1).Right hepatectomy was performed in 2 patients,left hepatectomy in 3 patients,right posterior sectionectomy in 3 patients,segmentectomy in 2 patients,and partial hepatectomy in 4 patients.99mTc-GSA scintigraphy and computed tomography(CT)were performed to construct 3D-99mTc-GSA scintigraphy/vascular fused images.The conventional volume ratio of the planned resection region without tumor(%CT),and the functional volume ratio of the planned resection region without tumor(%GSA)were calculated.The discrepancy ratio was calculated as follows:discrepancy ratio=100-%GSA/%CT×100(%).Results:The%GSA(17.9±16.7%)was significantly lower than the%CT(21.5±17.6%)(P<0.036).In all except 2 patients,the%GSA was lower than the%CT.The discrepancy ratio ranged from-4%to 75%(median,20.7%).Conclusion:3D-99mTc-GSA scintigraphy/vascular fused images constructed using SYNAPSE VINCENT were useful for noninvasively performing functional liver volumetry in patients scheduled to undergo various patterns of hepatectomy.In planned resection regions without tumor,the functional volume ratio was about 20%lower than the conventional volume ratio.