Effects of door-to-tolvaptan time on short-term clinical outcome in patients with acute heart failure.

AIMS: We investigated the effects of door-to-tolvaptan (D2T) time on short-term urine volume and in-hospital clinical outcomes in patients with acute heart failure (AHF). METHODS AND RESULTS: Patients with AHF, treated with tolvaptan at two hospitals, were enrolled in this retrospective observational study. The D2T time was defined as the time elapsed from the arrival of a patient at a participating hospital to the first administration of tolvaptan. The group with the D2T time within 6 h was defined as the 'early group'. The primary outcome was 48-h urine volume. The secondary outcomes were in-hospital death, length of hospital stay, and worsening renal function (WRF) incidence. A restricted cubic spline model was used to evaluate the presence of a nonlinear association between the D2T time and 48-h urine volume and the odds ratio of WRF incidence. Our study included a total of 138 patients with AHF who were started on tolvaptan after hospitalization. The median D2T time was 5.3 h (interquartile range: 3.0-31.9 h). Seventy-four patients (53.6%) were classified to be in the early group. Baseline characteristics were similar in the two groups: mean age (85.4 ± 9.6 years vs. 84.5 ± 9.5 years; P = 0.59) and male sex (n = 22 [33.3%] vs. n = 29 [46%]; P = 0.16), except that patients in the early group had higher systolic blood pressure than those in the delayed group (138.2 ± 22.9 vs. 125.7 ± 21.7; P = 0.001). The initial tolvaptan dose in the delayed group was much lower than that in the early group (7.5 [7.5, 7.5] vs. 7.5 [5.6, 7.5] mg; P = 0.01). Total urine volume in 48 h did not differ in the early and delayed groups (4113 ± 1758 mL vs. 4201 ± 1893 mL; P = 0.80). The relationship between D2T time and total urine volume within 48 h increased slightly, with a peak at a D2T time of 15 h, and gradually decreased, thereafter. In-hospital death and the length of hospital stay did not differ significantly between the two groups (n = 1, 1.3% vs. n = 4, 6.3%; P = 0.18, and 5.0 [12.0, 30.0] vs. 22.0 [14.5, 30.0] days; P = 0.17, respectively). Notably, the restricted cubic spline model for the odds ratio of WRF incidence increased as the D2T time was delayed (P for effect<0.01). CONCLUSIONS: The shorter D2T time did not affect the short-term urine volume and in-hospital outcomes but reduced the risk of WRF incidence in patients with AHF.

Penetration and Perforation of Terminal Ileum Diverticulitis.

BACKGROUND: Terminal ileum diverticulitis is a rare clinical disease. It can frequently mimic other processes, such as acute appendicitis. Diagnosis and therapeutic decision making (surgical or conservative treatment) can be complex. We report four interesting cases of terminal ileum diverticulitis. Case Presentation. Case 1: a 55-year-old male presented to us with a 3-day history of severe right lower quadrant pain. Computed tomography (CT) showed penetration of terminal ileum diverticulitis. Following a 7-day conservative treatment, he underwent ileocecal resection. Pathology results revealed a false diverticulum and two in five points of perforated terminal ileum diverticulum. Case 2: a 77-year-old male presented to us with severe right lower quadrant pain and unconsciousness. CT showed penetration of terminal ileum diverticulitis and air in the mesentery. Ileocecal resection was performed 2 days postadmission. Pathology results revealed a false diverticulum and penetrated terminal ileum diverticulum. Case 3: a 61-year-old male presented to us with a right lower quadrant pain for 10 days and fever for 6 days. CT showed penetration of terminal ileum diverticulitis and abscess of the psoas muscle. Puncture and drainage of abscess were performed. Laparoscopic ileocecal resection was performed 30 days postadmission. Pathology results revealed a false diverticulum and penetrated terminal ileum diverticulum. Case 4: a 39-year-old female presented to us with right lower quadrant pain for 9 days, suspicious of appendicitis. CT showed abscess of pericecal area. Puncture and drainage were performed. A drainage tube was located into the cecum through the terminal ileum. Conservative therapy was effective, and she was discharged 23 days postadmission. CONCLUSIONS: All four cases had right lower quadrant pain. Three cases were diagnosed by CT, whereas one was diagnosed by abscess drainage. Two cases required surgical treatment within 3 days, one within about 1 month, and one case did not require surgery. The decision of whether to manage a patient surgically or conservatively is difficult. It is critical not to delay the decision of performing a surgical treatment until each patient reaches a stable general condition.

Sclerosing Angiomatoid Nodular Transformation of the Spleen: Lessons from a Rare Case and Review of the Literature.

Sclerosing angiomatoid nodular transformation (SANT) of the spleen is an extremely rare benign lesion. We herein report a case of asymptomatic SANT of the spleen in a middle-aged woman with early breast carcinoma and an undiagnosed splenic mass, which was successfully treated by laparoscopic splenectomy and diagnosed postoperatively. We also review the literature on SANT to help make knowledge more accessible when clinicians encounter a splenic tumor. The present case taught us the following lesson: the presence of a splenic lesion during follow-up for malignancy is not always indicative of metastasis. Therefore, SANT should be considered in the differential diagnosis.

[A Resected Case of Cancer in the Ileum of the Blind Loop after an Ileotransverse Colostomy].

We report a resected case of cancer at the ileum of the blind loop. An 81-year-old male underwent an appendectomy for acute appendicitis and an ileotransverse colostomy for postoperative obstruction when he was 14 years old. He underwent radiation therapy for prostate cancer when he was 75 years old. Six years later, enhanced computed tomography revealed a 7 cm mass in the ileum of the blind loop. Colonoscopy showed wall thickening at the ileum of the blind loop, and biopsy revealed an adenocarcinoma. We performed partial resection of the ileum. The patient was discharged 17 days after surgery. Cancer at the ileum of the blind loop after an ileotransverse colostomy has rarely been reported.

Tumescent TAPP: laparoscopic inguinal hernia repair after the preperitoneal tumescent injection of diluted lidocaine and epinephrine saline solution and carbon dioxide gas.

PURPOSE: Laparoscopic transabdominal preperitoneal inguinal hernia repair (TAPP) is technically difficult and not infrequently followed by postoperative complications and pain, especially when performed by inexperienced surgeons. To simplify TAPP and reduce postoperative pain, we devised a novel procedure whereby TAPP is carried out after the inguinal preperitoneal infiltration of diluted lidocaine and epinephrine saline solution and carbon dioxide gas (tumescent TAPP). This report introduces the concept of tumescent TAPP and summarizes its operative results. METHODS: About 120 ml of diluted lidocaine and epinephrine solution and 60 ml of CO2 gas were infiltrated into the inguinal preperitoneal space through a transabdominal needle before TAPP. Tumescent TAPP was performed for 400 patients (355 men, 45 women; mean age, 63.2 years). RESULTS: Using tumescent TAPP, we found it easier to confirm the inguinal anatomy and dissect the preperitoneal layer and inguinal floor, with less bleeding. The mean operation time was 101.9 min and there were few perioperative complications and minimal pain. CONCLUSIONS: Tumescent TAPP makes conventional TAPP easier and safer; however, this procedure should be verified by a comparative study with conventional TAPP.

Laparoscopic repair of a diaphragmatic hernia associated with radiofrequency ablation for hepatocellular carcinoma: lessons from a case and the review of the literature.

We describe the case of a patient with a diaphragmatic hernia associated with radiofrequency ablation for hepatocellular carcinoma who was successfully treated by laparoscopic surgery. A 62-year-old man with a long history of hepatitis C-induced liver cirrhosis was admitted to our institution because of recurrent postprandial periumbilical pain. Eight years earlier, he had undergone radiofrequency ablation for hepatocellular carcinoma at hepatic segment VIII. Computed tomography, gastrografin enema examination revealed transverse colon obstruction because of a diaphragmatic hernia. We diagnosed diaphragmatic hernia associated with the prior radiofrequency ablation treatment. The patient underwent laparoscopic repair of the diaphragmatic hernia. Though the patient experienced the recurrence once, relaparoscopic treatment has improved the patient's conditions. Thus, diaphragmatic hernia can develop as a complication of radiofrequency ablation treatment. A laparoscopic approach is safe, feasible, and minimally invasive, even in patients with cirrhosis who develop iatrogenic diaphragmatic hernia as a complication of radiofrequency ablation treatment.

Laparoscopic resection of a retroperitoneal liposarcoma: a case report and review of the literature.

Here, we describe a case of a retroperitoneal liposarcoma successfully managed by laparoscopic surgery. A 72-year-old man underwent abnormal hypertension screening using computed tomography (CT), which revealed a low-density mass measuring 7 cm in diameter in the retroperitoneal space. We diagnosed the mass as a liposarcoma before the operation. The mass was resected laparoscopically. No perioperative complications were encountered, and the patient was discharged on the fourth postoperative day. The pathologic diagnosis was well-differentiated liposarcoma, indicating complete surgical resection. Thus, we conclude that a laparoscopic approach for the patients with retroperitoneal tumors, including liposarcomas, is safe, feasible, and minimally invasive, even if there is a possibility of the tumor being malignant.

Mesothelin expression is a prognostic factor in cholangiocellular carcinoma.

Although mesothelin is highly expressed in epithelial mesotheliomas, and also in adenocarcinomas of the ovary and pancreas, the clinical significance of mesothelin in cholangiocellular carcinoma (CC) has not been reported, and its biologic features are largely unknown. In the present study, mesothelin expression was evaluated in 25 patients with CC using a well-characterized mesothelin monoclonal antibody (5B2). A total of 8 of the 25 patients with CC (32%) showed mesothelin immunoreactivity. The 25 patients were divided into 2 groups according to the percentage of tumor cells that were positive for mesothelin expression: negative (n = 17) or focally positive (mesothelin expression evident in less than 50%, n = 4; total, n = 21 for both groups), and positive (mesothelin expression evident in 50% or more, n = 4). The survival periods in both groups were statistically analyzed. The negative/focally positive group showed significantly longer postoperative survival than the positive group (P = 0.006). Also, mesothelin positivity was identified as an independent predictor of short postoperative survival. The present results suggest that mesothelin expression is a prognostic indicator in patients with CC.

[A case of mucinous cystadenocarcinoma of the appendix with abdominal wall abscess successfully treated by percutaneous drainage and systemic chemotherapy-a case report].

A 76-year-old woman was diagnosed of mucinous cystadenocarcinoma of the appendix. Since there was wide direct invasion into the right psoas muscle, she was judged as inoperable although she had no bowel obstruction. She was received FOLFIRI and bevacizumab treatment. After the first cycle, the tumor progressed rapidly and formed the abdominal wall abscess at the right groin. Since she had a fever and pain at the right groin and the abscess reached the hypodermic, we put a drainage tube into the abscess. The tube was placed, which made her symptoms improved markedly. We have been continuing with FOLFIRI treatment and drainage for 10 months without progressive disease. We report a rare case of the conservative therapy of mucinous cystadenocarcinoma of appendix with abdominal wall abscess.

Late-onset venous outflow obstruction treated by placement of a Foley balloon catheter in living donor liver transplantation using a left lobe.

A 60-yr-old man having hepatitis C virus-associated liver cirrhosis and hepatocellular carcinoma underwent living donor liver transplantation using a left liver graft. On post-operative day 20, the patient developed a large amount of ascites and hypovolemic shock because of decreased venous return. Emergency laparotomy revealed that fixation of the round ligament to the abdominal wall was loose, and free movement of the graft into the right subphrenic space had caused twisting the hepatic vein. After upward traction of the round ligament, two Foley balloon catheters were inserted into the right subphrenic space to maintain the graft in the midline portion. The catheters with the balloons were removed on day 30 after re-operation. This method is easy, simple and inexpensive for the treatment of hepatic venous outflow block after partial liver transplantation.