Intussusception of Heterotopic Gastric Mucosa in the Transverse Colon: A Rare Cause of Perforation and Bleeding.

Heterotopic gastric mucosa in the colorectal region is a rare condition and can be found throughout the gastrointestinal tract. Intussusception in adults is mostly associated with adenocarcinoma and requires prompt surgical intervention, especially in cases of intestinal perforation. Our case report demonstrates a cecal perforation caused by the intussusception of heterotopic gastric mucosa within the transverse colon. The patient presented with substantial hematochezia. Despite the challenges of diagnosing this condition preoperatively and in the ICU, accurate pathologic evaluation is important. The consideration of a heterotopic gastric mucosa is crucial in cases of persistent hematochezia, especially in cases of intussusception. The postoperative course of the patient was characterized by hematochezia, which improved with proton pump inhibitors. The consideration of the possibility of heterotopic gastric mucosa may be a guide to appropriate surgical management and optimization of patient outcomes.

Isolated Pancreatic Metastasis From Renal Clear Cell Renal Cell Carcinoma 29 Years After Radical Nephrectomy.

Isolated metastatic tumors of the pancreas from other origins are only 2-3% of pancreatic cancers, and renal cell carcinoma is the most common origin of metastasis. It is challenging to differentiate between pancreatic tumors and those with a history of renal cancer to optimize treatment and management of this tumor. Here, we present a case of isolated renal cell cancer metastasis to the pancreas, which occurred 29 years after the radical nephrectomy. Surgical resection and pancreatectomy is a feasible treatment because of the low rate of complication and favorable prognosis. However, isolated metastatic pancreatic cancer from renal cell cancer is rare and has relatively high risk of recurrence. Therefore, a larger sample size is necessary to evaluate long-term oncologic outcomes and to optimize diagnostic and therapeutic strategies.

Effect of Preoperative Oral Antibiotics and Mechanical Bowel Preparations on the Intestinal Flora of Patients Undergoing Laparoscopic Colorectal Cancer Surgery: A Single-Center Prospective Pilot Study.

INTRODUCTION:  In the last few decades, considerable progress has been made in controlling surgical site infections (SSIs) using a combination of mechanical and oral antibiotic bowel preparation. However, the number of bacteria present after bowel preparation has not been clarified. In this study, we investigated the bacterial cultures of intestinal fluid samples from patients undergoing laparoscopic surgery for colorectal cancer after preoperative bowel preparation. METHODS: This prospective observational study was designed as a pilot study at a single center. We enrolled 25 consecutive patients who underwent laparoscopic surgery for colorectal cancer between March 2021 and February 2022 at our institution. RESULTS: The rate of bacterial culture positivity was 56.0%. The most abundant bacterium was Escherichia coli (44.0%). The positivity rates for E. coli on the right and left sides were 54.5% and 35.7%, respectively (P = 0.60). Moreover, there was a significant relationship between a low American Society of Anesthesiologists Physical Status score and E. coli positivity on the right side (P = 0.031). In the left-sided group, female sex and large tumor size were significantly associated with E. coli positivity (P = 0.036 and 0.049, respectively). Superficial SSI occurred in the patient in the left-sided group, but E. coli was negative. CONCLUSION: This study emphasizes the importance of understanding intestinal fluid contamination and its relationship to infection risk. Future prospective multicenter studies should be conducted to determine the association between intestinal bacteria and different types of preoperative preparation.

Duodenal neuroendocrine tumor after bilateral breast cancer with type 1 neurofibromatosis: a case report.

BACKGROUND: Young women with NF1 are at a high risk of developing breast cancer. Although they are at risk for abdominal tumors, such as gastrointestinal stromal tumors and neuroendocrine tumors, follow-up strategies for other tumors after breast cancer have not yet been established. Here, we present a case of duodenal neuroendocrine tumor found during follow-up after bilateral mastectomy for breast cancer with type 1 neurofibromatosis (NF1), for which pancreaticoduodenectomy (PD) and lymphadenectomy were performed. CASE PRESENTATION: A 46-year-old woman with NF1 was referred to our hospital for treatment of a duodenal submucosal tumor. Her previous operative history included bilateral mastectomy for breast cancer: right total mastectomy and left partial mastectomy performed 9 and 5 years ago, respectively. Her daughter was confirmed to have NF1, but her parents were unclear. Although she had no recurrence or symptoms during the follow-up for her breast cancer, she wished to undergo 18-fluorodeoxyglucose-positron emission tomography (FDG-PET) for systemic screening. FDG-PET demonstrated FDG accumulation in the duodenal tumor with a maximum standardized uptake value of 5.78. Endoscopy revealed a 20-mm-diameter tumor in the second duodenal portion, and endoscopic biopsy suggested a NET G1. We performed PD and lymphadenectomy for complete. She was doing well without recurrence and was followed up with PET tomography-computed tomography. CONCLUSIONS: Early detection of gastrointestinal tumors is difficult, because most of them are asymptomatic. Gastrointestinal screening is important for patients with NF1, and PD with lymphadenectomy is feasible for managing duodenal neuroendocrine tumors, depending on their size.

Laparoscopic subtotal cholecystectomy for difficult cases of acute cholecystitis: a simple technique using barbed sutures.

BACKGROUND: Laparoscopic cholecystectomy (LC) for difficult acute cholecystitis (AC) cases bears a high risk of vasculobiliary injuries (VBI). The Tokyo Guidelines 2018 (TG18) recommend the use of bailout procedures and subtotal cholecystectomy to prevent VBI. Performing a safe LC is challenging, even when followed by an accurate pre-surgical assessment. Laparoscopic cholecystectomy (LSC) requires advanced skills, and there is a risk of recurrence of cancer and/or gallbladder stones (GBS) in the remnant gallbladder (GB). Moreover, it is sometimes impossible to safely close the cystic duct with either a loop tie or linear staples because of anatomical and fragility problems. Here, we report a novel technique employing barbed sutures for LSC in difficult AC cases. CASE PRESENTATION: We performed urgent LSC using barbed sutures for the stump of the cystic duct in two patients. In preoperative assessments, we found that these cases were qualified for operations rather than GB drainages, but the cystic ducts appeared difficult to close due to their severe inflammation and fragility during the operations. We applied barbed suture as a surrogate technique to close the stump of cystic duct. In patient 1, a 67-year-old woman with severe heart failure and type 2 diabetes mellitus was diagnosed with grade III AC. Pathological diagnosis was gangrenous cholecystitis. In patient 2, a 68-year-old woman who was referred to our hospital after 15 days of treatment for AC with antibiotics without drainage. The severity of AC was grade II according to TG18. Pathological diagnosis was acute-on-chronic cholecystitis. Both patients were discharged without complication. CONCLUSIONS: The utilization of barbed sutures in LSC stems as a feasible and safe surrogate technique. Furthermore, this approach could decrease the risks associated with the remnant GB.

Serious intestinal bleeding from vascular ectasia secondary to portal thrombosis after living-related liver transplantation in a child.

Serious intestinal bleeding from vascular ectasia secondary to extrahepatic portal thrombosis is much less frequent than variceal bleeding, and its treatment is not clearly defined. We describe a 4-year-old girl with repeated intestinal bleeding from vascular ectasia, without any varix, with late extrahepatic portal vein thrombosis (PVT) and late hepatic artery thrombosis (HAT) after living-related liver transplantation. The bleeding stopped after simple splenectomy. She has presented neither bleeding nor any serious complications related to splenectomy for 1 year to date. We think uncontrollable hemorrhage from gastrointestinal vascular ectasia secondary to extrahepatic portal thrombosis in a pediatric patient can and should be treated by simple splenectomy, because patients with this complication usually have a normally functioning liver. However, it is not clear whether this procedure is effective for variceal bleeding.

Successful use of anti-CD20 monoclonal antibody (rituximab) for ABO-incompatible living-related liver transplantation.

BACKGROUND: Humoral rejection after ABO-incompatible liver transplantation often causes graft loss and a life-threatening situation. We used rituximab, which can eliminate B cells highly selectively, as an additional therapy for ABO-incompatible living-related liver transplantation. CASES: Patient 1 was a 1-year-old girl with biliary atresia. Her blood type was O, and the donor's was A. She underwent two plasma exchanges before liver transplantation and had triple immunosuppressants (mycophenolate mofetil, tacrolimus, and methylprednisolone). She was diagnosed with humoral rejection by needle biopsy on postoperative day 6. Rituximab was used for 3 days at 375, 187, and 187 mg/m(2) and successfully reduced the antibody titer, transaminase, and CD19(+) cells count in peripheral blood lymphocytes. The patient has not had any severe rejection, infection, or serious complications 2 years posttransplantation. Patient 2 was a 42-year-old woman with primary biliary cirrhosis. The blood type was O, and the donor's was B. She received three plasma exchanges, triple immunosuppressants, splenectomy, intraarterial anticoagulant therapy, and rituximab (375 mg/m(2) immediately after transplantation). The titer and CD19(+) cells count remained persistently low throughout the recovery course. She did not develop humoral rejection 1 year after transplantation. CONCLUSIONS: Rituximab efficiently reduces anti-ABO antibody titer by selectively eliminating B cells and is safe and effective against humoral rejection after ABO-incompatible liver transplantation.

Giant hepatic metastasis from gastrointestinal stromal tumor of the rectum 12 years after surgery.

Gastrointestinal stromal tumors are non-epithelial neoplasms that arise from the gastrointestinal tract. Their variable cytologic atypia makes it difficult to predict their prognosis. We report a case of right hepatectomy for a giant metastasis detected 12 years after the surgical treatment of a rectal neoplasm, histologically demonstrated as a low-grade leiomyosarcoma initially, having morphological and immunohistochemical features of low malignancy. Histological examination of the hepatic metastases demonstrated that the tumors were composed of spindle cells similar to those in the rectal neoplasm. Immunohistochemical staining of the hepatic metastases with Ki-67 revealed stronger than the primary tumor. In conclusion, although histological and immunohistochemical analyses provide useful prognostic information, the prognosis of gastrointestinal stromal tumors is difficult to predict. Therefore, a patient with gastrointestinal stromal tumor diagnosed as low-grade malignancy requires carefully long-term follow-up.

Portal vein pressure is the key for successful liver transplantation of an extremely small graft in the pig model.

In partial-liver transplantation, the use of small grafts sometimes results in graft failure, usually caused by portal hypertension after transplantation (Tx). Portal hypertension after Tx can be decreased with a porto-caval shunt (PCS). The purpose of this study is to clarify the effect of the PCS on extremely reduced-size liver Tx. In a pig model, the posterior segment of 25% of a whole liver was transplanted orthotopically. The pigs were divided two groups: group A, graft with PCS ( n=7), and group B, graft without PCS ( n=7). The PCS was made by means of side-to-side anastomosis of the portal vein and the inferior vena cava. We examined the portal vein pressure, survival rate, regeneration rate of the graft, Ki-67 as an index of cell proliferation, and histological findings, and carried out liver-function tests. In group A, five pigs survived for more than 4 days and the remaining two died of a perforated gastric ulcer on post-operative day (POD) 2. In group B, all pigs except one died of graft failure within 24 h. Portal vein pressure after reperfusion in group A and group B was of statistically significant difference ( P<0.05), 14.2+/-3.2 and 18.9+/-4.7 cmH(2)O, respectively. In group A, the regeneration rate of the graft was 94%, 4 days after Tx, and Ki-67 stained remarkably in the parenchymal hepatocytes. In TEM finding, structure of the sinusoid was also well maintained after Tx. From these results we can conclude that the key to success in liver Tx with extremely small grafts lies in the control of the portal vein pressure.

The safety of the donor operation in living-donor liver transplantation: an analysis of 45 donors.

We retrospectively assessed the safety of the donor operation, based on parameters such as blood loss, blood transfusion, operation time, duration of hospitalization, and complications. Forty-five pediatric and adult recipients underwent living-donor liver transplantation (LDLTx) in Tohoku University Hospital from July 1991 to October 2000. Donor operations were classified into three groups. In the LS group, the graft was the lateral segment ( n=20); in the LL group, the graft was the left lobe without the middle hepatic vein ( n=16); and in the LLM group, the graft was the left lobe with the middle hepatic vein ( n=9). No significant differences were observed among the three groups regarding postoperative liver function or duration of hospitalization. In the LS group, the operation time was shorter and the requirement of autologous blood transfusion was significantly lower than in the other two groups. Most complications following retrieval of the graft were minor. Safety is guaranteed when the left lobe or the left lateral segment is used for LDLTx, but meticulous management of the operation is required to prevent complications.

Successful liver transplantation from agonal non-heart-beating donors in pigs.

An effective way to overcome shortage of donors in liver transplantation (LTx) is to consider such from non-heart-beating donors (NHBDs). We investigated how a liver graft should be treated before and/or after procurement for successful LTx from an NHBD. Porcine LTx was performed with FR167653 (FR), a dual inhibitor of tumor necrosis factor-alpha (TNF-alpha) and interleukin-1beta (IL-1beta), and/or prostaglandin E(1) (PG). Animals were allocated to an FR group (n=4, donors and recipients were treated with FR), a PG group (n=4, donors and recipients were treated with PG), or an FRPG group (n=4, donors and recipients were treated with both FR and PG). No recipients in the FR group and only two of four recipients in the PG group survived, whereas all recipients in the FRPG group survived. Suppression of TNF-alpha and IL-1beta and maintenance of microcirculation are the key to successful transplantation from NHBDs.

[ABO-incompatible liver transplantation and patients with hepatopulmonary syndrome].

From 1991 to 2000, more than 100 ABO-incompatible liver transplantations were performed in 12 institution in Japan. The overall survival rate is 60%. Survival data appear to have improved in these years even in adult cases, although acute vascular rejection causing hepatic necrosis, infection, and intrahepatic bile duct injury are major complications to be resolved. Hepatopulmonary syndrome (HPS) was considered to be a contraindication to transplantation in the 1980s. However, even severe cases can recover from hypoxia after liver transplantation, and improved survival data were reported in the 1990s. Intensive respiratory therapy after transplantation with NO inhalation allows expansion of the indications for transplantation in HPS.