[Primary Volvulus of the Small Intestine Mimicking Nonocclusive Mesenteric Ischemia Following Open-heart Surgery].

A 73-year-old female who underwent aortic valve replacement with a biological valve, coronary artery bypass, and left atrial appendage closure had sudden onset of nausea and abdominal pain 43 days after surgery. She had a history of nonocclusive mesenteric ischemia on 4th postoperative day, for which conservative management was successfully carried out. A contrast-enhanced computed tomography(CT) was performed because a recurrence of nonocclusive mesenteric ischemia was suspected. It revealed a whirl sign in the small intestine, suggestive of small intestine volvulus. At the subsequent emergency laparotomy, volvulus caused severe congestion in the small intestine, aproximately 40 cm from the cecum. However, there was no evidence of transmural necrosis, and reduction of torsion notably improved blood supply to the small intestine. Her regular diet was resumed on 4th postoperative day, and her postoperative course was uneventful. Volvulus should be considered as a differential diagnosis in the setting of acute abdominal pain after open-heart surgery.

Surgical management for peritoneal carcinomatosis of appendiceal origin with a high-tumor burden.

PURPOSE: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) is the active treatment for peritoneal carcinomatosis of appendiceal origin. However, surgical management is sometimes difficult in patients with a high-tumor burden. METHODS: A high-tumor burden was defined as a peritoneal cancer index (PCI) ≥ 28. Among 49 patients receiving CRS + HIPEC, 29 had a PCI ≥ 28. RESULTS: Complete cytoreduction (CC-0/1) was achieved in 20 of the 29 patients with a PCI ≥ 28 and in all 20 patients with a PCI < 28. Among the patients achieving CC-0/1, gastrectomy or total colectomy was performed more frequently, the hospital stay was longer and postoperative complications were more frequent in those with a PCI ≥ 28 than in those with a PCI < 28. If CC-0/1 was achieved, the overall survival was comparable between patients with a PCI ≥ 28 and a PCI < 28. However, the recurrence-free survival was significantly worse for patients with a PCI ≥ 28 than for those with a PCI < 28 (5-year survival: 73.7% vs. 5.9%). Patients with recurrence who underwent repeat CRS showed a better overall survival than those without repeat CRS. Among patients with a PCI ≥ 28, a performance status (PS) of 2/3 was a significant prognostic factor (hazard ratio = 5.132). CONCLUSIONS: In patients with a high-tumor burden undergoing CRS + HIPEC, postoperative complications were more frequent, and the recurrence rate was higher than in those without a high-tumor burden. Repeat CRS improved the survival of patients with recurrence. The PS was a key indicator when selecting patients suitable for aggressive resection.

Repeat cytoreduction and hyperthermic intraperitoneal chemotherapy for recurrent peritoneal carcinomatosis of appendiceal origin.

BACKGROUND: The purpose of this study was to clarify the role of repeat cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) in the management of recurrent peritoneal carcinomatosis of appendiceal origin. METHODS: Data were retrieved on 42 patients who underwent CRS + HIPEC; 29 repeat surgical procedures were performed in 13 patients. RESULTS: Complete cytoreduction was achieved in 12 of 13 patients by the second CRS. Repeat recurrence was detected in 11 patients, eight of whom underwent a third CRS. The peritoneal cancer index decreased from initial CRS to repeat CRS but was still higher than 18 in nine patients at the second CRS. Preoperative chemotherapy was given to three patients with early recurrence. Grade 3-5 morbidity and 90-day mortality were not significantly different between initial and repeat CRS. Five-year survival rates after first and second CRS were 75.5 and 67.7%, respectively. Complete cytoreduction at second CRS was a significant prognostic factor. Among patients with recurrence after the second CRS, patients who underwent a third CRS showed a better prognosis than those who did not. CONCLUSIONS: Repeat CRS is oncologically beneficial, and the morbidity rate was as high as that of initial CRS. Complete cytoreduction was the key to successful long-term results. Although further recurrence was common, aggressive resection was useful, even in cases of diffuse recurrence.

Indications for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in elderly patients with peritoneal malignancy.

PURPOSE: A combination of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) is effective for some peritoneal malignancies. However, the indications for elderly patients remain unclear, with substantial postoperative morbidity and mortality being problematic. MATERIALS: Clinical data were analyzed in 42 patients undergoing CRS + HIPEC for peritoneal malignancy. The primary tumor was located in the appendix in 32 cases and elsewhere in 10 cases. Operative results and survival data were compared between patients aged ≥70 and <70 years. RESULTS: Fourteen patients were older than 70 years. Elderly patients had a higher peritoneal cancer index (32.0 vs. 21.5), higher CA19-9 level (189.0 vs. 28.1), and higher frequency of grade 4-5 complications (5/9 vs. 2/26) than the younger patients. Grade 4-5 respiratory failure occurred in three elderly patients. There was a significant difference of postoperative survival between the elderly patients and younger patients, with 5-year survival rates being 41.3 and 74.2%, respectively (p = 0.0166). The poor prognosis of elderly patients was related to the higher frequency of grade 4-5 complications. CONCLUSIONS: Elderly patients were referred for treatment with more advanced disease than younger patients. An age ≥70 years was associated with more frequent grade 4-5 complications and worse survival. Performing CRS + HIPEC in elderly patients should be considered carefully due to the risk of severe complications, especially respiratory failure.

Phase I clinical trial of olprinone in liver surgery.

PURPOSE: Post-hepatectomy liver failure is one of the most serious complications liver surgeons must overcome. We previously examined olprinone, a selective phosphodiesterase III inhibitor, and demonstrated its hepatoprotective effects in rats and pigs. We herein report the results of a phase I clinical trial of olprinone in liver surgery (UMIN000004975). METHODS: Twenty-three patients who underwent hepatectomy between 2011 and 2015 were prospectively registered. In the first 6 cases, olprinone (0.1 µg/kg/min) was administered for 24 h from the start of surgery. In the remaining 17 cases, olprinone (0.05 µg/kg/min) was administered from the start of surgery until just before the transection of the liver parenchyma. The primary endpoint was safety, and the secondary endpoint was efficacy. For the evaluation of efficacy, the incidence of post-hepatectomy liver failure in 20 hepatocellular carcinoma patients was externally compared with 20 propensity score-matched patients. RESULTS: No intraoperative side effects were observed, and the morbidity rates in the analyzed cohorts were acceptable. The rate of post-hepatectomy liver failure frequency tended to be lower in the olprinone group. CONCLUSIONS: The safety of olprinone in liver surgery was confirmed. The efficacy of olprinone will be re-evaluated in clinical trials.

A non-smooth tumor margin on preoperative imaging predicts microvascular invasion of hepatocellular carcinoma.

PURPOSES: Microvascular invasion (mVI) is known to be a risk factor of hepatocellular carcinoma (HCC) recurrence. Several factors such as the tumor grade, tumor size, tumor margin status on imaging studies, fluorine-18 fluorodeoxyglucose-positron emission tomography ((18)F-FDG-PET) results, and tumor markers have been proposed to predict mVI of HCC. However, the values of these factors have not yet been validated. METHODS: Among the patients evaluated using enhanced CT/MRI, (18)F-FDG-PET, and tumor markers prior to hepatectomy from 2007 to 2012, 79 HCC patients without apparent macrovascular invasion in preoperative imaging were enrolled in this study. The image tumor margin status (smooth/non-smooth), (18)F-FDG-PET, and tumor markers, which were previously described as predictors for mVI, were evaluated. RESULTS: Fifteen patients had mVI (mVI+ group) and 64 patients had no evidence of mVI (mVI- group) on pathological examinations. A univariate analysis showed that the mVI+ group had a higher SUV and TNR (5.2 vs 3.8, p = 0.02 and 1.8 vs 1.3, p = 0.02, respectively) and a higher portion of non-smooth tumor margin (87 vs 27 %, p = 0.0001). There was no significant difference in the tumor markers. A multivariate analysis showed that non-smooth tumor margin alone could independently predict mVI (odds ratio 18.3, 95 % CI 3.27-102.6, p = 0.0009). CONCLUSION: A non-smooth tumor margin on preoperative imaging predicts microvascular invasion of HCC.

Validation of the Conventional Resection Criteria in Patients with Hepatocellular Carcinoma in Terms of the Incidence of Posthepatectomy Liver Failure and Long-Term Prognosis.

BACKGROUND/AIMS: Resection criteria in hepatocellular carcinoma (HCC) should be established based on the risk of posthepatectomy liver failure (PHLF) and the survival benefit from hepatectomy. This study aimed at verifying the validity of the conventional criteria regarding the incidence of PHLF and the long-term prognosis of HCC patients. METHODS: A retrospective study was performed on 265 patients who underwent major hepatectomy. Makuuchi's criteria and the future liver remnant plasma clearance rate of indocyanine green (ICGK-rem) ≥0.05 criterion were evaluated. RESULTS: A total of 107 and 158 patients were within and beyond Makuuchi's criteria, respectively. Makuuchi's criteria were associated with the incidence of PHLF (p = 0.03) but not with its severity (p = 0.12). No differences in disease-free survival (DFS) or overall survival (OS) were observed between the groups (p = 0.75 and p = 0.94, respectively). Using the ICGK-rem ≥0.05 criterion, 223 and 42 patients were within and beyond the criterion, respectively. ICGK-rem was correlated with both the incidence of PHLF (p = 0.002) and its severity (p = 0.03). No differences in DFS or OS were observed between the groups (p = 0.75 and p = 0.29, respectively). CONCLUSIONS: Strict criteria are likely to preclude some patients from obtaining the greater survival benefits of hepatectomy. New criteria that consider patient prognosis are needed.

Hepatoprotective effect by pretreatment with olprinone in a swine partial hepatectomy model.

Excessive portal flow to a small remnant liver or small-for-size graft is a primary factor of small-for-size syndrome. We demonstrated that olprinone (OLP), a phosphodiesterase III inhibitor, had a hepatoprotective effect in a rat extended hepatectomy model and a small-for-size liver transplantation model through a modification of the portal venous pressure (PVP). To identify the appropriate dose and duration of treatment for clinical applications, we conducted experiments with a swine partial hepatectomy model. Twenty microminipigs were divided into 4 groups that received the following treatments: (A) saline (control group), (B) OLP at 0.3 µg/kg/minute (preoperative and postoperative administration), (C) OLP at 0.1 µg/kg/minute (preoperative administration), and (D) OLP at 0.3 µg/kg/minute (preoperative administration). The pigs underwent 70% partial hepatectomy. Hemodynamic changes, including changes in PVP, were examined. Liver biopsy was performed 1 and 3 hours after hepatectomy. Blood samples were collected until postoperative day 7 (POD7). In comparison with group A, PVP elevations, periportal edema, and sinusoidal hemorrhaging were attenuated after left Glisson's ligation in groups C and D. Pretreatment with OLP in groups C and D preserved the microstructure of sinusoids and improved the prothrombin activity 1 and 3 hours after hepatectomy. These animals showed better recovery of the remnant liver volume and the plasma disappearance rate of indocyanine green on POD7. In contrast, group B showed exacerbation of liver damage. Measurements of the serum OLP concentration showed that 10 ng/mL OLP was appropriate for a hepatoprotective effect. In conclusion, pretreatment with OLP shows hepatoprotective effects in a swine partial hepatectomy model. OLP may have the potential to ameliorate patients' outcomes after hepatectomy or liver transplantation.

Glycine inhibits angiogenic signaling in human hepatocellular carcinoma cells.

Hepatocellular carcinoma (HCC) is a highly vascularized tumor with limited susceptibility to chemotherapy. Modern targeted therapies are aimed at specific properties of this neoplasm. Glycine is a simple non-essential amino acid with potential antiangiogenic effects. In this study, the amino acid's effect on angiogenic signaling in an in vitro model of HCC was evaluated. HepG2 and Huh7 cells were treated with glycine-free DMEM supplemented with 0, 0.01, 0.1, 1.0, 2.0, 5.0 and 10 mM glycine. The direct effects of glycine on the viability of HCC cells were monitored using MTT assay. To detect angiogenic signaling, mRNA and protein levels of vascular endothelial growth factor (VEGF-A) were measured using RT-PCR and Western Blot assays. To determine whether or not glycine receptors (GlyR) played a significant role, the specific antagonist, strychnine, was used as a direct inhibitor. Western Blotting was performed to show the presence of GlyR. While there was no direct pro- or antiproliferative effect of either glycine or strychnine in both cell lines, glycine was shown to significantly decrease VEGF-A expression on mRNA and protein level up to 63 % in both cell lines. This effect was blunted by the presence of strychnine. GlyR was also identified in both cell lines. Glycine decreases GlyR-dependent, VEGF-A-mediated, angiogenic signaling in human HCC and thus might be a promising additive to chemotherapy treatment strategies for highly vascularized tumors.

Effects of oral intake of hydrogen water on liver fibrogenesis in mice.

AIM: Liver fibrosis is the universal consequence of chronic liver diseases. Sustained hepatocyte injury initiates an inflammatory response, thereby activating hepatic stellate cells, the principal fibrogenic cells in the liver. Reactive oxygen species are involved in liver injury and are a promising target for treating liver fibrosis. Hydrogen water is reported to have potential as a therapeutic tool for reactive oxygen species-associated disorders. This study aimed to investigate the effects of hydrogen water on liver fibrogenesis and the mechanisms underlying these effects. METHODS: C57BL/6 mice were fed with hydrogen water or control water, and subjected to carbon tetrachloride, thioacetamide and bile duct ligation treatments to induce liver fibrosis. Hepatocytes and hepatic stellate cells were isolated from mice and cultured with or without hydrogen to test the effects of hydrogen on reactive oxygen species-induced hepatocyte injuries or hepatic stellate cell activation. RESULTS: Oral intake of hydrogen water significantly suppressed liver fibrogenesis in the carbon tetrachloride and thioacetamide models, but these effects were not seen in the bile duct ligation model. Treatment of isolated hepatocyte with 1 µg/mL antimycin A generated hydroxyl radicals. Culturing in the hydrogen-rich medium selectively suppressed the generation of hydroxyl radicals in hepatocytes and significantly suppressed hepatocyte death induced by antimycin A; however, it did not suppress hepatic stellate cell activation. CONCLUSION: We conclude that hydrogen water protects hepatocytes from injury by scavenging hydroxyl radicals and thereby suppresses liver fibrogenesis in mice.

The impact of posthepatectomy liver failure on the recurrence of hepatocellular carcinoma.

BACKGROUND: Patients with hepatocellular carcinoma (HCC) who underwent hepatectomy often developed an intrahepatic recurrence, even though it was a curative one. The relationship between surgery-induced liver damage and the recurrence of HCC has not been described. This study evaluated whether posthepatectomy liver failure, as defined by the International Study Group of Liver Surgery, affected the recurrence of HCC. METHODS: We performed a retrospective cohort study of 488 patients with HCC who underwent hepatectomy between 2004 and 2012 at Kyoto University Hospital. Early posthepatectomy liver failure (EPLF) was defined as liver failure occurring between postoperative days 5 and 10. The patients were divided into an EPLF group and a non-EPLF group. Disease-free survival (DFS) was compared between these groups. The influences of host-related, surgery-related, and tumor-related factors on patient outcomes were evaluated using multivariate analyses. RESULTS: The EPLF group and the non-EPLF group contained 153 and 335 patients, respectively. The probability of DFS was significantly increased in the non-EPLF group (median: 574 days) compared to the EPLF group (median: 348 days) (hazard ratio, HR [95 % confidence interval, CI] 1.61 [1.29-2.00]). The multivariate analysis revealed that EPLF was an independent factor for DFS (HR [95 % CI] 1.43 [1.13-1.81]), besides the factors previously described, including fibrosis (1.32 [1.05-1.67]), stage (1.85 [1.34-2.51]), tumor differentiation (1.46 [1.11-1.89]), and des-γ-carboxyprothrombin (1.39 [1.10-1.74]). CONCLUSIONS: EPLF was associated with postoperative HCC recurrence. The prevention of EPLF might improve the prognosis of patients with HCC.

A single-center analysis of the survival benefits of adjuvant gemcitabine chemotherapy for biliary tract cancer.

BACKGROUND: Surgical resection is the only curative treatment of biliary tract cancer (BTC). However, the prognosis of BTC remains unsatisfactory. The aim of this study is to evaluate the benefits of adjuvant gemcitabine chemotherapy for BTC. METHODS: We performed a historical cohort study that involved 198 patients who underwent R0 surgical resection. Patients who underwent major hepatectomy were administered biweekly intravenous gemcitabine at a dose of 800 mg/m(2). Otherwise, patients were administered intravenous gemcitabine at a dose of 1,000 mg/m(2) in 3 weekly infusions, which were followed by a 1-week pause. The primary outcome was overall survival. The hazard ratio (HR) of adjuvant chemotherapy was estimated by propensity score-stratified Cox regression that was adjusted for confounders. RESULTS: Forty patients received adjuvant chemotherapy. The HR of adjuvant chemotherapy was 0.47 [95 % confidence interval (CI) 0.28-0.95; P = 0.03]. Subgroup analysis showed that the survival benefits were possibly modified by lymph node positivity (HR 0.19; 95 % CI 0.07-0.58; interaction, P = 0.22), stage III (HR 0.11; 95 % CI 0.02-0.50; interaction, P < 0.01), intrahepatic cholangiocarcinoma (ICC) (HR 0.09; 95 % CI 0.01-0.67; interaction, P = 0.05), and poorly differentiated tumor (HR 0.16; 95 % CI 0.03-0.85; interaction, P = 0.13). CONCLUSIONS: Adjuvant gemcitabine chemotherapy for BTC may be effective, particularly for patients with stage III and ICC.

Effect of emergency general surgery on postoperative performance status in patients aged over 90 years.

Background: Functional deterioration following emergency general surgery (EGS) poses a significant challenge in super-elderly patients. However, limited research has focused on assessing the deterioration in postoperative performance status (PS). This study aimed to investigate the impact of EGS on PS deterioration in super-elderly patients, and the extent to which deteriorated PS is recovered. Methods: This historical cohort study comprised 77 super-elderly patients who underwent EGS between July 2015 and December 2020. Functional deterioration was evaluated by comparing preoperative and postoperative Eastern Cooperative Oncology Group Performance Status (ECOG-PS). The Emergency Surgical Score (ESS) was used as a risk-adjustment tool. Questionnaires were mailed to the patients and their families to assess post-discharge PS and obtain their impressions of EGS. Results: Postoperative PS deteriorated in 35/77 patients (45.5 %). Significant differences were observed between the groups in terms of sex, serum C-reactive protein (CRP) levels, ESS scores, preoperative ECOG-PS, duration of operation, and major complications. Multivariate analysis of preoperative factors showed that ESS ≥7 (OR: 3.7, 95 % CI: 1.0-13), preoperative ECOG-PS ≤2 (OR: 5.9, 95 % CI: 1.7-21), and female sex (OR: 5.8, 95 % CI: 1.6-21) were associated with postoperative ECOG-PS deterioration. According to the questionnaire results, PS recovery post-discharge was observed in 6/36 (17 %) patients, and 34/36 (94 %) patients and their families expressed positive impressions of EGS. Conclusions: EGS in super-elderly patients highly caused a deterioration in their PS, particularly in patients with maintained preoperative PS. PS hardly recovered; however, most patients and their families had positive impressions of the EGS. Key message: We assessed the pre- and postoperative performance status of super-elderly patients who underwent emergency general surgery. Surgery caused a marked deterioration in patients' functional performance, which seldom recovered postoperatively.

Effect of olprinone on liver microstructure in rat partial liver transplantation.

BACKGROUND: Donor safety is a major concern in living-donor liver transplantation. However, partial grafts do not meet the functional demands of recipients and lead to small-for-size syndrome (SFSS). In a previous study, we showed that olprinone (OLP), a selective phosphodiesterase ІІІ inhibitor, up-regulates endothelial nitric oxide synthase level in the liver and attenuates shear stress, sinusoidal endothelial cell injury, and hepatocyte apoptosis after excessive liver resection in a rat model. We aimed to examine whether OLP treatment has beneficial effects on SFSS in a rat model of partial liver transplantation (PLT). METHODS: We performed experiments in a rat model of 30% PLT. In the OLP group, we inserted an osmotic pump with OLP into the peritoneal cavity 48 h before liver graft sampling. Recipient rats were not treated with OLP. We examined the liver microstructure by electron microscopy and biochemical examination, and determined the 7-d survival of recipients. RESULTS: In the OLP group 1 h after PLT, the sinusoidal endothelial cells of the liver were well preserved and we observed few vacuolar structures in hepatocytes. The total serum bilirubin level 1 wk after PLT tended to be lower in the OLP group than in the controls, and the liver microstructures were also well preserved in the OLP group. The probability of survival in the OLP group (100%; 14 of 14 rats) was significantly higher than that in the control group (75%; 15 of 20 rats). CONCLUSIONS: Olprinone treatment was demonstrated to have therapeutic potential to overcome SFSS.

Preoperative FDG-PET predicts recurrence patterns in hepatocellular carcinoma.

PURPOSE: We investigated the usefulness of preoperative fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) as a tool for predicting recurrence patterns to select patients for liver resection as an initial surgical strategy for hepatocellular carcinoma. METHODS: Sixty-three consecutive hepatocellular carcinoma patients undergoing FDG-PET were enrolled. They were classified according to the initial recurrence patterns (beyond the Milan criteria [MC], within the MC, and no recurrence) and the time intervals before initial postoperative recurrence (within 1 year, after 1 year or later, and no recurrence). The tumor-to-nontumor ratio (TNR) obtained by FDG-PET and survival rates were compared among the groups. RESULTS: TNR in the recurrence within the MC group (1.9 ± 1.6) and no recurrence group (1.3 ± 1.5) was significantly lower than that in the beyond the MC group (2.9 ± 2.6). TNR was an independent predictive factor of recurrence patterns in multivariate analysis. TNR in the groups with recurrence after 1 year or later (1.6 ± 0.8) and no recurrence (1.3 ± 0.5) were significantly lower than that in the within 1-year group (3.1 ± 2.7). TNR was an independent predictive factor of the interval before initial recurrence by multivariate analysis. CONCLUSIONS: Preoperative FDG-PET predicts hepatocellular carcinoma recurrences within the MC or no recurrence and recurrences after 1 year or later. FDG-PET may be useful for selecting appropriate patients for liver resection as an initial surgical strategy.

An eClinical trial system for cancer that integrates with clinical pathways and electronic medical records.

BACKGROUND: Various information technologies currently are used to improve the efficiency of clinical trials. However, electronic medical records (EMRs) are not yet linked to the electronic data capture (EDC) system. Therefore, the data must be extracted from medical records and transcribed to the EDC system. Clinical pathways are planned process patterns that are used in routine clinical practice and are easily applicable to the medical care and evaluation defined in a trial protocol. However, few clinical pathways are intended to increase the efficiency of clinical trials. PURPOSE: Our purpose is to describe the design and development of a new clinical trial process model that enables the primary use of EMRs in clinical trials by integrating clinical pathways and EMRs. METHODS: We designed a new clinical trial model that uses EMR data directly in clinical trials and developed a system to follow this model. We applied the system to an investigator-initiated clinical trial and examined whether all data were extracted correctly. At the protocol development stage, our model measures endpoints based on clinical pathways with the same diagnosis. Next, medical record descriptions and the format of the statistical data are defined. According to these observations, screens for entry of data, which are used both in clinical practice and for study, are prepared into EMRs with an EMR template, and screens are prepared for data checks on our EMR retrieval system (ERS). In an actual trial, patients are registered and randomly assigned to a protocol treatment. The protocol treatment is executed according to clinical pathways, and the data are recorded to EMRs using EMR templates. The data are checked by a local data manager using reports created by the ERS. After edit checks and corrections, the data are extracted by the ERS, archived in portable document format (PDF) with an electronic signature, and transferred in comma-separated values (CSV) format to a coordinating centre. At the coordinating centre, the data are checked, integrated, and made available for a statistical analysis. RESULTS: We verified that the data could be extracted correctly and found no unexpected problems. LIMITATION: To execute clinical trials in our system, the EMR template and efficient ERSs are required. Additionally, to execute multi-institutional clinical trials, it is necessary to create templates appropriate for EMRs at all participating sites and for the coordinating centre to validate local templates and procedures. CONCLUSION: We proposed and pilot tested a new eClinical trial model. Because our model is integrated with routine documentation of clinical practice and clinical trials, redundant data entries were avoided and the burden on the investigator was minimised. The reengineering of the clinical trial process would facilitate the establishment of evidence in the future.

Emergency open drainage of massive hemoperitoneum and early stage left hepatectomy for abdominal compartment syndrome due to hepatocellular carcinoma rupture: a case report.

BACKGROUND: Spontaneous rupture is one of the most life-threatening complications of hepatocellular carcinoma (HCC). Transcatheter arterial embolization (TAE) effectively achieves hemostasis in patients with hemodynamic instability. However, there have been no reports of abdominal compartment syndrome (ACS) caused by massive intra-abdominal hematoma after TAE. We report emergency open drainage of a massive hematoma for abdominal decompression and early stage left hepatectomy at the same time. CASE PRESENTATION: A 75-year-old woman was transported to our emergency department with hypovolemic shock. Dynamic contrast-enhanced computed tomography revealed extravasation of contrast medium from a HCC lesion in the medial segment of the liver and a large amount of high-density ascites. TAE was immediately performed to achieve hemostasis. Three hours after the first TAE, we decided to perform a second TAE for recurrent bleeding. After the second TAE, the patient's intra-abdominal pressure increased to 35 mmHg, her blood pressure gradually decreased, and she had anuria. Thus, she was diagnosed with ACS due to spontaneous HCC rupture. Twenty-seven hours after her arrival to the hospital, we decided to perform open drainage of the massive hematoma and left hepatectomy for ACS relief, prevention of re-bleeding, tumor resection, and intraperitoneal lavage. The operative duration was 225 min, and the blood loss volume was 4626 g. Postoperative complications included pleural effusion and grade B liver failure. She was discharged on postoperative day 33. The patient survived for more than 3 years without functional deterioration. CONCLUSIONS: Even after hemostasis is achieved by TAE for hemorrhagic shock due to spontaneous rupture of HCC, massive hemoperitoneum may lead to ACS, particularly in cases of re-bleeding. Considering the subsequent possibility of ACS and the recurrence of bleeding, early stage hepatectomy and removal of intra-abdominal hematoma after hemodynamic stabilization could be a treatment option for HCC rupture.

Evaluating the outcomes of primary anastomosis with hand-sewn full-circular reinforcement in managing perforated left-sided colonic diverticulitis.

Background: It is a challenge to avoid stoma formation in emergency surgery of perforated left-sided diverticulum. The hand-sewn full-circular reinforcement of the colorectal anastomosis is used during complete pelvic peritonectomy to avoid a diverting ileostomy. This study examined the effect of applying the reinforcement method to perforated left-sided colonic diverticulitis with respect to the permanent stoma rate and cost-effectiveness. Materials and methods: This historical cohort study examined all patients who underwent emergency surgery for perforation of a left-sided diverticulum at the Hyogo Prefectural Amagasaki General Medical Center between July 2015 and September 2019. The cohort was divided into two groups: those who underwent conventional method (Group F) and those for whom the hand-sewn full-circular reinforcement method was actively performed (Group L). Results: The number of patients who underwent emergency surgery which did not lead to an ostomy increased significantly from 12% (3/25) in Group F to 42% (11/26) in Group L (P = 0.0015). The rate of permanent stoma decreased from 80% in Group F to 27% in Group L (P < 0.001). Total treatment costs for patients under the age of 80 in Group L were significantly lower than those in Group F (2170000 ± 1020000 vs 3270000 ± 1960000 JPY; P = 0.018). Conclusions: In emergency surgery for left-sided perforated colonic diverticulitis, applying the hand-sewn full-circle reinforcement of the anastomotic site may reduce stoma formation at the initial surgery and consequently decrease permanent stoma rate and contribute to cost-effectiveness without increasing complications such as anastomotic leakage.

Clinical impact of bloodstream infection on acute cholecystitis indicated for emergency cholecystectomy.

BACKGROUND: The significance of blood culture for acute cholecystitis remains unclear. METHODS: A retrospective cohort study was conducted on patients who underwent emergency cholecystectomy at Hyogo Prefectural Amagasaki General Medical Center to examine the clinical impact of bloodstream infection (BSI), focusing on the association of BSI with bactibilia and severity grade based on the Tokyo guidelines 2018 (TG18). RESULTS: Among 177 patients included in the study, 32 had positive and 145 had negative BSI. Significant differences were observed between the positive and negative BSI in terms of age, body mass index (BMI), the American Society of Anesthesiologists physical status (ASA-PS) and TG18 severity score. The odds ratios of BSI for patients aged ≥72 years, with a BMI of ≤21.8, an ASA-PS of ≥3E, and grade III acute cholecystitis were 3.45, 3.23, 2.43 and 4.51, respectively. In the multivariate analysis, lower BMI and grade III were significantly associated with BSI with odds ratios of 2.53 (95% confidence interval: 1.07-6.21, P = .037) and 3.03 (95% confidence interval: 1.02-8.82, P = .041). Bacterial species that could not be isolated in the bile culture alone were identified in blood culture on 10 (38.5%) of 26 patients. CONCLUSIONS: Bloodstream infection is associated with grade III acute cholecystitis. Blood culture enables the identification of bacteria that cannot be isolated in bile culture. Blood culture should be obtained for patients with grade III acute cholecystitis who undergo emergency cholecystectomy.

Proliferative activity in hepatocellular carcinoma is closely correlated with glucose metabolism but not angiogenesis.

BACKGROUND & AIMS: This study investigated the relationship between tumor proliferative activity and the grade of tumor glucose metabolism or angiogenesis in hepatocellular carcinoma (HCC). METHODS: The study was performed as a retrospective analysis of 63 patients with HCC who underwent fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) as a preoperative examination prior to liver resection. Tumor proliferative activity was evaluated by the Ki-67 labeling index (LI). The grade of tumor glucose metabolism was evaluated by measuring the protein expression level of glucose transporter (GLUT)-1, expression level of pyruvate kinase type M2 (PKM2) mRNA, and FDG uptake. The grade of tumor angiogenesis was evaluated by the protein expression level of vascular endothelial growth factor (VEGF) and tumor microvessel density. RESULTS: All patients were divided into tertiles according to the Ki-67 LI: the low LI group (n = 21), the intermediate LI group (n = 21), and the high LI group (n = 21). The high LI group showed a tendency to have advanced tumor stage, and lower disease-free survival and overall survival rates than the low LI and the intermediate LI groups. The expression grade of GLUT-1, PKM2 mRNA, and FDG uptake gradually increased with the Ki-67 LI. On the other hand, the protein expression grade of VEGF and microvessel density was paradoxically decreased with the Ki-67 LI. CONCLUSIONS: These data suggest that (1) the proliferative activity of a resected specimen predicted the prognosis in patients with HCC; (2) the proliferative activity was closely correlated with the glucose metabolism, but not with angiogenesis.