Perioperative red blood cell transfusion and mortality following heart transplantation: A retrospective nationwide population-based study between 2007 and 2016 in Korea.

BACKGROUND: Patients undergoing heart transplantation (HT) frequently receive perioperative red blood cell (RBC) transfusions, but the impact of perioperative transfusion on clinical outcomes after HT remains unclear. METHODS: All adult HTs performed in Korea between 2007 and 2016 were analyzed using data from the National Health Insurance Service. Patients were classified into four groups based on the number of RBC units transfused during hospital admission for HT: 0, 1 to 2, 3 to 5, and greater than or equal to 6 units. In-hospital and long-term mortality rates were compared among the groups. RESULTS: In total, 833 adults HTs were included in the study. The overall in-hospital mortality rate was 8.4% (70 of 833), with no mortality occurring in patients who received no transfusion. The in-hospital mortality rate was higher in patients requiring greater than or equal to 6 units (25.1%) than in patients who received 1 to 2 units (0.3%) and 3 to 5 units (2.7%; P < .001). Patients who received greater than or equal to 6 units of RBCs had a significantly higher risk of all-cause mortality after HT compared to patients who received no transfusion (hazard ratio [95% confidence interval], 5.99 [1.46-24.56]; P = .012). Long-term survival rate was also lower in patients who received transfusions of greater than or equal to 6 units of RBCs than in patients who received no transfusion (P < .001). CONCLUSIONS: Perioperative transfusion of greater than or equal to 6 units of RBCs may be associated with an increased risk of in-hospital and long-term mortality after HT.

Adult lung transplantation case-volume and in-hospital and long-term mortality in Korea.

BACKGROUND: The inverse relationship between case-volume and surgical mortality has been reported in complex surgical procedures. The aim of this study was to evaluate the effect of case-volume on mortality after lung transplantation in Korea. METHODS: The National Health Insurance Service data was used to analyse all adult lung transplantations in Korea between 2007 and 2016. Institutions were categorized into low-volume (< 5 lung transplantations/year) centers or high-volume (≥ 5 lung transplantations/year) centers. Risk-adjusted in-hospital mortality and long-term survival according to case-volume was evaluated. RESULTS: A total of 315 adult recipients underwent lung transplantation at 7 centers. The odds ratio for in-hospital mortality in low-volume centers was similar to high-volume centers (OR, 1.496; 95% CI, 0.81-2.76; p = 0.197). Log-rank analysis of Kaplan-Meier curves according to case-volume also did not show a difference in long-term survival between high- and low-volume centers (p = 0.052). CONCLUSIONS: There was no association between case-volume and in-hospital mortality after lung transplantation in Korea, although there was a tendency towards better long-term survival associated with high-volume centers.

Aortoenteric fistula following overlap esophagojejunal anastomosis using linear staplers for cancer of the esophagogastric junction: a case report.

BACKGROUND: Aortoenteric fistula (AEF), occasionally reported as a fatal complication after aortic or other vascular procedures, is a communication between the aorta and the digestive tract. AEF as a fatal complication of overlap esophagojejunostomy after esophagogastrectomy has not been reported previously. Herein, we report a case of AEF after laparoscopic proximal gastrectomy and transhiatal lower esophagectomy for cancer of the esophagogastric junction, in which linear staplers were used for overlap esophagojejunostomy. CASE PRESENTATION: A 66-year-old woman with advanced cancer of the esophagogastric junction underwent laparoscopic proximal gastrectomy and transhiatal lower esophagectomy with abdominal and lower mediastinal lymphadenectomy. Double tract reconstruction by the overlap method was performed. The patient was discharged from the hospital 10 days after surgery with a good postoperative course. However, she developed sudden-onset massive hematemesis and melena the day after discharge, resulting in death. Autopsy revealed that the stapled edge of the entry hole of the overlap esophagojejunostomy was in direct contact with the descending aorta. AEF was found at the esophagojejunostomy site. CONCLUSIONS: To our knowledge, this is the first report of AEF as a fatal complication of overlap esophagojejunostomy after esophagogastrectomy. Although we could not definitively identify the cause of the AEF, it could be attributed to direct contact between the stapled edge and the bare thoracic aorta over a period of 10 days. To avoid direct contact with the aorta in esophagojejunostomy with linear staplers, all stapled edges should be covered by suturing and attention should be paid to the position of these edges.

Effect of Case Volume on Mortality After Pediatric Liver Transplantation in Korea.

BACKGROUND: The purpose of this study was to evaluate whether institutional case-volume affects clinical outcomes after pediatric liver transplantation. METHODS: We conducted a nationwide retrospective cohort study using the database of Korean National Healthcare Insurance Service. Between January 2007 and December 2016, 521 pediatric liver transplantations were performed at 22 centers in Korea. Centers were categorized according to the average annual number of liver transplantations: >10, 1 to 10, and <1. RESULTS: In-hospital mortality rates in the high-, medium-, and low-volume centers were 5.8%, 12.5%, and 32.1%, respectively. After adjustment, in-hospital mortality was significantly higher in low-volume centers (adjusted odds ratio, 9.693; 95% confidence interval, 4.636-20.268; P < 0.001) and medium-volume centers (adjusted odds ratio, 3.393; 95% confidence interval, 1.980-5.813; P < 0.001) compared to high-volume centers. Long-term survival for up to 9 years was better in high-volume centers. CONCLUSIONS: Centers with higher case volume (>10 pediatric liver transplantations/y) had better outcomes after pediatric liver transplantation, including in-hospital mortality and long-term mortality, compared to centers with lower case volume (≤10 liver transplantations/y).

Squamous cell carcinoma of the extrahepatic bile duct with metachronous para-aortic lymph node metastasis successfully treated with S-1 plus cisplatin.

The most common histological classification of bile duct cancer is adenocarcinoma and squamous cell carcinoma (SCC) is relatively rare. We report a case of a 78-year-old man with SCC of the extrahepatic bile duct associated with metachronous para-aortic lymph node metastasis. He had undergone subtotal stomach-preserving pancreatoduodenectomy. The pathological findings demonstrated moderately differentiated SCC of the distal extrahepatic bile duct (T1N1M0, stage IIB). 6 months after surgery, recurrence of the para-aortic lymph node was shown in abdominal CT. 5 courses of tegafur/gimeracil/oteracil (S-1) plus cisplatin therapy was performed and the para-aortic lymph node disappeared, confirmed as complete response by imaging findings. The patient is alive without recurrence, 10 months after recurrence and chemotherapy.

Strangulated transmesosigmoid hernia as a late complication of a fall from a height: A case report.

INTRODUCTION: A transmesosigmoid hernia is defined as small bowel herniation through a complete defect involving both layers of the sigmoid mesentery. Blunt trauma injury to the sigmoid mesocolon has been reported only rarely. We herein report a case of a strangulated transmesosigmoid hernia associated with a history of a fall from a height. PRESENTATION OF CASE: A 43-year-old woman presented to our hospital for evaluation of vomiting. She had no history of abdominal surgery but had sustained a complete spinal cord injury and pelvic fracture secondary to a fall from a height 25 years earlier. A computed tomography scan of her abdomen and pelvis demonstrated a closed loop of small bowel in the pelvis, with a zone of transition in the left lower abdomen. Although the cause of the obstruction was difficult to establish, ischemia was strongly suspected; therefore, the decision was made to perform emergency exploratory laparoscopy. During laparoscopy, a loop of ileum was observed to have herniated through a full-thickness defect in the sigmoid mesocolon, consistent with a transmesosigmoid hernia. The herniated loop was strangulated but not gangrenous and was successfully reduced using laparoscopic graspers. The incarcerated small bowel appeared viable and was therefore not resected. The defect was closed with a running suture. The patient had an uneventful postoperative course with no recurrence. DISCUSSION AND CONCLUSION: Abdominal blunt trauma can cause sigmoid mesenteric rupture resulting in a transmesosigmoid hernia. In the management of transmesosigmoid hernias, laparoscopic herniorrhaphy has the advantage of facilitating simultaneous diagnosis and surgical intervention.

[Efficacy of hepatic arterial infusion chemotherapy with cisplatin for advanced hepatocellular carcinoma].

BACKGROUND: Transcatheter arterial chemoembolization (TACE) was performed as the initial therapy for advanced hepatocellular carcinoma (HCC). However, no effective chemotherapy has been established for patients who did not respond to TACE, and for those the therapy was not suitable. Since 2004, transcatheter arterial infusion (TAI) chemotherapy using fine-powder cisplatin has been applied at our department to such cases mentioned before. This report described the therapeutic results of TAI therapy and presented a case of HCC accompanied by portal vein tumor thrombus (PVTT) for which the therapy was effective. PATIENTS AND METHODS: TAI was performed using cisplatin in 16 patients with inoperable advanced HCC between 2004 and 2010. Cisplatin was infused into the proper hepatic artery at a dose of 65 mg/m2 for 30 minutes. RESULTS: TAI was performed in each patient 1.8 times on average, ranging from 1 to 8 times. Therapeutic Effect 4 (TE4) was obtained in 1 case, TE3 in 2, TE2 in 1, and TE1 in 11 cases. The only severe adverse event rated as grade 3 or above during the study were nausea and anorexia reported in 6.3% of the patients, and adverse events rated as less than grade 2 were increased serum hepato-biliary enzyme levels in 68.8%, nausea in 68.8% of the patients. The overall 1-year survival rate was 31.2%, and the 50% survival period was 314 days. CONCLUSION: As a treatment option following the initial TACE therapy for advanced HCC, TAI using cisplatin can improve the prognosis of HCC.

Carcinoma of the ampulla of vater arising from the peribiliary gland.

The present paper reported a case of a carcinoma that probably developed from the peribiliary gland within the ampulla of Vater based on the histopathological findings of the resected specimens. A 49-year-old female became aware of epigastralgia and was diagnosis of stenosis of duodenal 2nd portion. There were no malignant findings on gastrointestinal endoscopy and computed thomography. Endoscopic retrograde cholangiopancreatography revealed no tumor in the main pancreatic duct or the common bile duct or ampulla of Vater. Pylorus preserving panctreaticoduodenectomy was performed with a diagnosis of duodenal stenosis of unknown cause. The histopathological findings revealed that a moderately to poorly differentiated adenocarcinoma originating near the peribiliary gland in the ampulla of Vater was extensively distributed in the submucosal layer of the duodenum. Based on these findings, a diagnosis of a carcinoma of the ampulla of Vater arising from the peribiliary gland was most likely suspected. Judging from the generally known development and extension of carcinoma of the ampulla of Vater, the current case appeared to be a very rare one.

[Two cases of advanced hepatocellular carcinoma with portal vein tumor thrombus responding to transcatheter arterial infusion chemotherapy using cisplatin].

We report two cases of advanced hepatocellular carcinoma( HCC) with a portal vein tumor thrombus (PVTT) responding to transcatheter arterial infusion chemotherapy (TAI) using cisplatin (CDDP). Case 1: A 65-year-old male patient was diagnosed with unresectable multiple HCCs. After 5 courses of transcatheter arterial chemoembolization (TACE), the tumor became markedly enlarged, and a PVTT (Vp2) and lymph node metastasis were noted. TAI was conducted as the second- line chemotherapy, and the liver tumor, PVTT, and lymph node metastasis shrank. The clinical response was rated as a partial response (PR). Case 2: A 72-year-old female patient was diagnosed with single HCC. After a course of TACE, the tumor became markedly enlarged and was accompanied by a PVTT (Vp4). TAI was performed as the second-line chemotherapy, and the liver tumor and PVTT significantly shrank. The clinical response was also rated as a PR. TAI using CDDP as the second-line chemotherapy for advanced HCC is a promising treatment likely to contribute to the improvement of the patient's prognosis.

Distinctive expression and function of four GSDM family genes (GSDMA-D) in normal and malignant upper gastrointestinal epithelium.

Gasdermin (GSDM or GSDMA), expressed in the upper gastrointestinal tract but frequently silenced in gastric cancers (GCs), regulates apoptosis of the gastric epithelium. It has three human homologs, GSDMB, GSDMC, and GSDMD (GSDM family) and they are considered to be involved in the regulation of epithelial apoptosis but not yet known. We investigated the expression pattern of the family genes in the upper gastrointestinal epithelium and cancers. Reverse transcriptase-polymerase chain reaction revealed that, unlike GSDMA expressed in differentiated cells, GSDMB is expressed in proliferating cells and GSDMD in differentiating cells. GSDMC, meanwhile, is expressed in both differentiating and differentiated cells. Colony formation assay showed that GSDMB, closely related to GSDMA, has no cell-growth inhibition activity in gastric cancer cells, and that GSDMC and GSDMD, respectively, exhibit the activity with different strengths from that of GSDMA. Expression analyses of the four family genes in esophageal and GCs suggested that GSDMC and GSDMD as well as GSDMA are tumor suppressors and that GSDMB, which was amplified and overexpressed in some GCs, could be an oncogene. The results of the expression analysis and colony formation assay suggest that each family gene may have a distinct function in the upper gastrointestinal epithelium.

[A phase I study of combination-therapy with gemcitabine and epitope peptides derived from human vascular endothelial growth factor receptor for unresectable or recurrent pancreas cancer].

We are performing a phase I clinical trial of combination-therapy with gemcitabine and epitope peptide derived from human vascular endothelial growth factor receptor (VEGFR) for advanced pancreas cancer. The aim of this study was to evaluate the safety, immunological response and tumor response. Six patients have been enrolled at present. During the clinical course, no major adverse events were observed. Additionally, two out of 6 cases showed a minor shrinkage of the tumor. Immunological response has not been analyzed yet. These results indicated that a combination-therapy with gemcitabine and epitope peptides derived from VEGFR could be tolerable.

Unruptured pseudoaneurysm of the cystic artery with acute calculous cholecystitis incidentally detected by computed tomography.

Pseudoaneurysm of the cystic artery is rare; to our knowledge, fewer than 30 cases have been reported worldwide. We report the first case of an unruptured pseudoaneurysm of the cystic artery with concurrent acute calculous cholecystitis. We incidentally detected the aneurysm by contrast-enhanced computed tomography (CT) in the edematous, thickened wall of the gallbladder neck in a 71-year-old man, whereas in most of the reported cases the disease presented as hemobilia. Because of the high risk of aneurysm rupture in this location, we avoided such interventions as percutaneous cholecystostomy and laparoscopic cholecystectomy. The aneurysm was localized pathologically in the undisrupted gallbladder wall, and elective open cholecystectomy with ligation of the cystic artery was performed successfully. Our case highlights the usefulness of CT for both diagnosis and patient management. Open cholecystectomy with ligation of the cystic artery is demonstrated as a reasonable first line of treatment for this unusual condition.

[Chemotherapy with gemcitabine after non-curative resection of bile duct cancer--a case report].

Non-curative resection for cholangiocarcinoma usually leads to a poor prognosis. We present a case successfully treated with gemcitabine for residual tumor after extra hepatic bile duct resection with positive surgical margin. The patient was a 77-year-old male who was diagnosed as having a common bile duct cancer. Extra hepatic bile duct resection was performed, but intraoperative pathology diagnosed the surgical margin of duodenal-side bile duct was positive for cancer. Although additional resection of bile duct was done, pathological diagnosis resulted in positive margin again. We had to avoid pancreatoduodenectomy in light of the patient's wishes, so a curative resection could not be carried out. Adjuvant chemotherapy with gemcitabine(800 mg/m2 on days 1, 8 and 15 every 4 weeks)was started at the seventh postoperative day. A residual lesion was shown in the pancreas head by abdominal CT after 2 courses of chemotherapy. Follow-up CT was performed every 6 months, and the lesion gradually seemed to become unclear. Finally, CT showed disappearance of the residual lesion 28 months after surgery. The chemotherapy has been continued up to the present(3 years and 5 months after surgery). No evidence of recurrence nor adverse events of WHO grade 2 or more has been observed.

Preoperative assessment for feasibility of laparoscopic cholecystectomy using magnetic resonance cholangiography.

BACKGROUND/AIMS: We present the results of classification of magnetic resonance cholangiography (MRC) focusing upon visualization of cystic duct for preoperative laparoscopic cholecystectomy (LC), along with assessments of a possible correlation between MRC classification and feasibility of LC. METHODOLOGY: The study included a total of 663 patients who were diagnosed as cholelithiasis. MRC were classified into four types: Type A; entire biliary tract was visualized (+), Type B; cystic duct (+) but gallbladder was not(-), Type C; gallbladder (+), cystic duct (-), and Type D; gallbladder (-), cystic duct (-). The feasibility of LC was assessed using the following two variables: 1) percentages of cases in which LC was changed to open cholecystectomy (OC) and 2) operating time. The results were compared in respect of the relationship with the MRC classification. RESULTS: MRC were classified as follows: Type A (58.4%), Type B (15.2%), Type C (19.3%) and Type D (7.1%). A total of 124 patients (18.7%) had chronic cholecystitis, and a strong correlation with MRC type was noted (p<0.0001). In 46 patients (7.5%), the surgical procedure was changed from LC to OC. The percentages of cases in which LC was changed to OC was significantly higher for Type C and Type D (p<0.0001), so these two groups demonstrated prolonged operating time. CONCLUSIONS: Our MRC classification based on the visualization of cystic duct can reflect the feasibility of LC, and LC may be less feasible tin Type C, and in particular Type D patients.

[Transradial approach for transcatheter arterial chemoembolization in patients with unresectable and recurrent hepatocellular carcinoma--a comparison with a conventional transfemoral approach].

We evaluated a clinical usefulness and safety of transradial approach for transcatheter arterial chemoembolization (TAE) in patients with unresectable and recurrent hepatocellular carcinoma (HCC) compared with that of conventional transfemoral approach. The two groups (radial group; n=385, 1999.7-2007.3, femoral group; n=150, 1997.4-1999.6) of cases were retrospectively compared with regard to the successful rate of angiography, TAE, interventional time, Lipiodol retention pattern and complications. Hepatic angiography and TAE were completed in 379 (98.4%) of 385 cases in the radial group. There was no inter-group difference of interventional time. Minor complications (dull pain or numbness of puncture site) occurred in 29 (7.6%) patients in the radial group. Transradial approach has some advantages as follows: (1) No time will be required to stop breeding after removal of sheath. (2) The patient may freely walk after the examination. TAE by our new transradial approach for HCC was found to have a therapeutic efficacy with lower complications comparable to that of conventional transfemoral approach.

Array-based comparative genomic hybridization of circulating esophageal tumor cells.

Esophageal squamous cell carcinoma (ESCC) shows a high frequency of lymphatic and/or systemic metastasis, even when the tumor invades only the submucosa. To investigate the genetic alterations in circulating esophageal tumor cells, we performed array-based comparative genomic hybridization (CGH) analysis of 8 DNA samples of xenografts, which were previously established from the thoracic duct lymph of 13 ESCC patients. A total of 5 loci (or genes), 10q21.3 (EGR2), 11q13.3 (CCND1/CyclinD1, FGF4, and EMS1), 11q14 (PAK1), and 22qtel (ARSA) were found to be candidate amplified loci in the xenograft. In contrast, a total of 24 loci including 9p21 (p16 and MTAP) were found to be homozygously deleted candidates in the xenograft. Both p16 homozygous deletion and CCND1 amplification were detected in 6 (75%) and 5 (62.5%) of the 8 xenografts. Furthermore, by quantitative Southern blot analysis, we found p16 homozygous deletion in 30.8% (8/26) of the primary tumors and in 50% (4/8) of the metastasized lymph nodes. The frequency of CCND1 amplification and p16 homozygous deletion is suggested to be associated with ESCC progression. Matrigel invasion assays of p16-deleted ESCC cells showed that restoring wild-type p16 activity into the cells significantly inhibits tumor-cell invasion, suggesting that p16 inactivation could be involved in ESCC invasion. This is the first report showing the genetic alteration of concealed tumor cells in the thoracic duct lymph. The present gene list should be helpful for identifying new amplified and deleted genes in primary ESCCs as well as in metastasized lymph nodes.