Indications for emergency surgery for perforated diverticulitis in elderly Japanese patients ≥80 years of age.

PURPOSE: Perforated diverticulitis (PD) remains a serious acute abdominal condition. The aim of this study was to evaluate indications for emergency surgery in patients ≥80 years of age with PD. METHOD: Twenty patients ≥80 years of age and 28 younger patients who underwent emergency surgery for PD from January 2002 to December 2011 were studied. The demographics and postoperative outcomes were compared. RESULTS: The preoperative characteristics, mortality rate, and postoperative complications were similar between these two groups. All seven patients ≥80 years of age with an American Society of Anesthesiologists (ASA) score of 2 survived after surgery. All five patients with a Mannheim peritonitis index (MPI) score of ≥26 in the elderly group died after surgery. There were significant associations between the mortality, the MPI and ASA score in patients ≥80 years of age. CONCLUSIONS: Best supportive care may be an alternative for patients ≥80 years of age with PD, an ASA score of ≥3 or an MPI score of ≥26.

Impact of antithrombin III concentrates on portal vein thrombosis after splenectomy in patients with liver cirrhosis and hypersplenism.

OBJECTIVE: The aim of this study was to determine the role of antithrombin III (AT-III) in portal vein thrombosis (PVT) after splenectomy in cirrhotic patients. SUMMARY BACKGROUND DATA: There is no standard treatment for PVT after splenectomy in liver cirrhosis. METHODS: A total of 50 consecutive cirrhotic patients who underwent laparoscopic splenectomy for hypersplenism were enrolled into this study. From January 2005 to December 2005, 25 cirrhotic patients received no prophylactic anticoagulation therapy after the operation (AT-III [-] group). From January 2006 to July 2006, 25 cirrhotic patients received prophylactic administration of AT-III concentrates (1500 U/d) on postoperative day (POD) 1, 2, and 3 (AT-III [+] group). RESULTS: In AT-III (-) group, 9 (36.0%) patients developed PVT up to POD 7, and risk factors for PVT were identified as: low platelet counts, low AT-III activity, and increased spleen weight. Although there were no significant differences in the clinical characteristics, including the above risk factors, between the 2 groups, only 1 (4.0%) patient developed PVT on POD 30 in AT-III (+) group, and the incidence of PVT was significantly lower than in AT-III (-) group (P = 0.01). In AT-III (-) group, AT-III activity was significantly decreased from POD 1 to POD 7, as compared with the preoperative level, whereas AT-III concentrates prevented the postoperative decrease in AT-III activity. CONCLUSIONS: These results demonstrate that low AT-III activity and further decreases in this activity are associated with PVT after splenectomy in cirrhotic patients, and that treatment with AT-III concentrates is likely to prevent the development of PVT in these patients.

Defective endothelial nitric oxide synthase signaling is mediated by rho-kinase activation in rats with secondary biliary cirrhosis.

In liver cirrhosis, down-regulation of endothelial nitric oxide synthase (eNOS) has been implicated as a cause of increased intrahepatic resistance. We investigated whether Rho-kinase activation is one of the molecular mechanisms involved in defective eNOS signaling in secondary biliary cirrhosis. Liver cirrhosis was induced by bile duct ligation (BDL). We measured mean arterial pressure (MAP), portal venous pressure (PVP), and hepatic tissue blood flow (HTBF) during intravenous infusion of saline (control), 0.3, 1, or 2 mg/kg/hour fasudil for 60 minutes. In BDL rats, 1 and 2 mg/kg/hour fasudil significantly reduced PVP by 20% compared with controls but had no effect on HTBF. MAP was significantly reduced in response to 2 mg/kg/hour fasudil. In the livers of BDL rats, 1 and 2 mg/kg/hour fasudil significantly suppressed Rho-kinase activity and significantly increased eNOS phosphorylation, compared with controls. Fasudil significantly reduced the binding of serine/threonine Akt/PKB (Akt) to Rho-kinase and increased the binding of Akt to eNOS. These results show in secondary biliary cirrhosis that (1) Rho-kinase activation with resultant eNOS down-regulation is substantially involved in the pathogenesis of portal hypertension and (2) Rho-kinase might interact with Akt and subsequently inhibit the binding of Akt to eNOS.

Effect of laparoscopic splenectomy on portal hypertensive gastropathy in cirrhotic patients with portal hypertension.

AIM: This study investigated the relationship between portal hypertensive gastropathy (PHG) and splenomegaly, and the effect of laparoscopic splenectomy on PHG in cirrhotic patients with portal hypertension. METHODS: Seventy patients with liver cirrhosis and portal hypertension were prospectively studied. Indication for laparoscopic splenectomy was bleeding tendency in 10 patients, induction of interferon in 45, treatment of hepatocellular carcinoma in seven, and treatment for endoscopic injection sclerotherapy-resistant esophagogastric varices in eight. The severity of PHG was classified into none, mild, or severe according to the classification by McCormack et al. The severity of liver disease was classified using the Child-Pugh score. All patients underwent upper gastrointestinal endoscopy before and 1 month after the operation. RESULTS: The prevalence of PHG was significantly correlated with the severity of liver disease using the Child-Pugh score. The severity of PHG was significantly correlated with the resected spleen volume. One month after the operation, PHG was improved in 16 of 17 patients with severe PHG and in 12 of 32 with mild PHG. The Child-Pugh score showed a significant improvement (6.8 +/- 1.4 to 6.2 +/- 1.2) at 3 months after laparoscopic splenectomy (P < 0.0001). CONCLUSIONS: PHG may be associated with splenomegaly, and laparoscopic splenectomy may have a beneficial effect on PHG, at least for a short time.

Technical standardization of laparoscopic splenectomy harmonized with hand-assisted laparoscopic surgery for patients with liver cirrhosis and hypersplenism.

BACKGROUND/PURPOSE: The aims of this study were to standardize the techniques of laparoscopic splenectomy (LS) to improve safety in liver cirrhosis patients with portal hypertension. METHODS: From 1993 to 2008, 265 cirrhotic patients underwent LS. Child-Pugh class was A in 112 patients, B in 124, and C in 29. Since January 2005, we have adopted the standardized LS including the following three points: hand-assisted laparoscopic surgery (HALS) should be performed in patients with splenomegaly (> or =1,000 mL), perisplenic collateral vessels, or Child-Pugh score 9 or more; complete division and sufficient elevation of the upper pole of the spleen should be performed before the splenic hilar division; and when surgeons feel the division of the upper pole of the spleen is too difficult, conversion to HALS should be performed. RESULTS: There were no deaths related to LS in this study. After the standardization, conversion to open surgery significantly reduced from 11 (10.3%) of 106 to 3 (1.9%) of 159 patients (P < 0.05). The average operation time and blood loss significantly reduced from 259 to 234 min (P < 0.01) and from 506 to 171 g (P < 0.01), respectively. CONCLUSIONS: With the technical standardization, LS becomes a feasible and safe approach in the setting of liver cirrhosis and portal hypertension.

Effect of thrombopoietin on platelet counts and liver regeneration after partial hepatectomy in a rat model.

PURPOSE: We investigated the effects of thrombopoietin (TPO) on platelet counts and liver regeneration after partial hepatectomy in rats. METHODS: We performed 70% partial hepatectomy on 60 rats given either TPO or a vehicle (controls). The rats were killed 6 h, 24 h, 72 h, or 168 h after the procedure, and we examined the platelet counts, weight of the regenerated liver, hepatocyte proliferation by bromodeoxyuridine (BrdU) labeling index, and expression of hepatocyte growth factor (HGF) mRNA by reverse transcription-polymerase chain reaction. RESULTS: In the controls, the platelet counts were significantly lower than the basal levels, by about 20%, at 6, 24, and 72 h; then recovered to the basal level at 168 h. Conversely, in the TPO-treated rats, the platelet counts increased significantly by 17%, 35%, and 60%, at 24, 72, and 168 h, respectively. The regenerated liver regained 80% of the pre-hepatectomy weight by 72 h in the controls, whereas reconstitution of the liver was accomplished by 72 h in the TPO-treated rats. Thrombopoietin significantly enhanced the BrdU labeling index of hepatocytes and expression of HGF mRNA 24 h post hepatectomy in TPO-treated rats versus controls. CONCLUSION: Thrombopoietin increased platelet counts; thereby accelerating liver regeneration after partial hepatectomy with enhanced induction of HGF.

[A case report--complete disappearance of multiple intrahepatic recurrences and portal thrombus in a case of hepatocellular carcinoma treated with UFT-E].

Here, we present a case of recurrent hepatocellular carcinoma(HCC)with portal thrombus that disappeared within only two months by oral tegafur(UFT-E). A 82-year-old man had recurrent multiple HCCs, which caused liver dysfunction because of diminished portal flow by the portal thrombus. Hepatic arterial chemo-embolization and continuous arterial CDDP-infusion chemotherapy did not show any efficacy. Next, oral UFT-E administration(low-dose, 300 mg/day)was begun, and after 1 month, PIVKA-II decreased and liver dysfunction was normalized. His complete response continued for 8 months until his death due to aspiration pneumonia and progressive dementia. Low-dose UFT-E administration may be considered a candidate in a case of HCC with no alternative treatment.

[A case of multiple liver and celiac lymph node metastases after curative esophagectomy for esophageal cancer successfully treated with hepatic arterial infusion and radiation therapy].

A 65-year-old woman, who had been operated by subtotal esophagectomy for esophageal cancer, was diagnosed as multiple liver metastases and celiac lymph node metastases one year after operation. The response evaluation revealed progressive disease after she had been suffering from nausea and anorexia throughout 2 courses of FP therapy. She refused to continue any more systemic chemotherapy, so we proposed an alternative to her, hepatic arterial infusion chemotherapy (HAI) for multiple liver metastases and radiation therapy for celiac LN metastases. Despite the marked reduction of all target lesions and maintenance of tumor marker level below the normal limits after 50 Gy of irradiation and 5 courses of HAI, a novel solitary tumor had appeared in S3 of the liver and an abdominal pain during HAI had occurred at the end of 5th course of HAI. The angiogram revealed occlusion of hepatic artery, suggesting that the emergence of new lesion was attributed to unequal distribution of the drug. Six weeks after a cessation of HAI, a subsequent CT scan showed a rapidly enlarged new lesion in S3, so that a surgical resection for this tumor was performed. The patient is alive without recurrence more than 10 months after the diagnosis of multiple liver metastases (2 months after the last surgery).

Abnormality of the hepatic vein waveforms in cirrhotic patients with portal hypertension and its prognostic implications.

BACKGROUND AND AIM: We investigated the prognostic significance of changes in the Doppler hepatic vein (HV) waveforms in cirrhotic patients with portal hypertension and the mechanisms of these changes. METHODS: A total of 103 consecutive patients were included in this study and their HV waveforms were classified into four types: type I, triphasic waveform; type II, biphasic waveform; type III, biphasic waveform with reduced phasic oscillations; and type IV, a flat waveform. RESULTS: Type I was observed in 34, type II in 40, type III in 23, and type IV in six patients. The 5-year survival rates were 90%, 89%, 41%, and 0% in type I, II, III, and IV, respectively. Five variables including the Child-Pugh score, albumin, bilirubin, ascites, and HV waveform significantly correlated with the survival in a univariate analysis. A multivariate analysis only identified the HV waveform (type III and IV) to be an independent prognostic value. Even in Child-Pugh class B patients, the 5-year survival rate for type III or IV was as poor as 26% in comparison to 92% for type I or II. In contrast, in Child-Pugh class C patients, the 5-year survival rate for type I or II was as good as 63% in comparison to 25% for type III or IV. Furthermore, the changes in HV waveforms correlated with the extent of hepatic fibrosis, the increase in portal perfusion per liver volume, or the decrease in portal vascular resistance. CONCLUSIONS: Analyzing the HV waveforms was thus found to be a simple method for accurately assessing the prognosis in cirrhotic patients with portal hypertension.

Laparoscopic disconnection of a huge paraumbilical vein shunt for portosystemic encephalopathy.

Chronic portosystemic encephalopathy (CPSE) resulting from portosystemic shunts (PSS) is a devastating clinical problem. When CPSE is refractory to medical treatment, occlusion of the PSS should be considered. We report a case of CPSE due to a huge paraumbilical vein shunt that was successfully treated with laparoscopic disconnection. A 54-year-old woman diagnosed with liver cirrhosis was referred to our department for treatment of hepatic encephalopathy. She had repeatedly experienced episodes of disturbance of consciousness, and had hyperammoniemia refractory to medical treatment. Computed tomography showed a huge patent paraumbilical vein connected to the systemic circulation through the round ligament. Laparoscopic disconnection of the paraumbilical vein shunt was performed. The postoperative course was uncomplicated and there has been no recurrence of hepatic encephalopathy in the 2 years since, nor has there been a need for further medical treatment. We believe this is the first case report of CPSE treated laparoscopically, and it demonstrates that laparoscopic disconnection of PSS, especially paraumbilical vein shunts, can be a safe and effective procedure to treat CPSE.

Malignant lymphoma incidentally diagnosed due to the perforation of the small intestine caused by a fish bone: A case report.

INTRODUCTION: The ingestion of a foreign body is relatively common. However, it rarely results in the perforation of gastrointestinal tract. We herein report an unusual case of malignant lymphoma incidentally diagnosed after the perforation of the small intestine by a fish bone. PRESENTATION OF CASE: A 90-year-old woman was admitted to our hospital because of abdominal pain and vomiting. Abdominal computed tomography demonstrated free air and ascites in the abdominal cavity. In the pelvic cavity, a radiopaque linear shadow about 35mm in diameter was shown in the small intestine, and the stricture was exposed to the abdominal cavity. Therefore, a diagnosis of perforation of the small intestine due to ingestion of a foreign body and panperitonitis was made. Emergent laparotomy was performed. The intraoperative findings revealed perforation of the small intestine with a fish bone in the jejunum. Local inflammation at the perforation site was seen, and circulated wall thickness was observed at the distal side of the jejunum. Partial resection of the jejunum and anastomosis of jejuno-jejunostomy was performed. A pathological examination and immunohistochemical study of the resected specimen resulted in a diagnosis of malignant lymphoma of follicular lymphoma Grade 1. DISCUSSION: It is very difficult to identify the existence malignancy accompanied with gastrointestinal perforation with ingestion of a foreign body. CONCLUSION: In cases suspected of involving malignancy, careful observation during surgery is needed in order to avoid missing the accompanying malignancy.

[A case of inoperable gastric small cell carcinoma effectively treated by chemotherapy and radiotherapy].

We herein report a case of advanced gastric small cell carcinoma treated by chemotherapy and radiotherapy. A 69-year-old man was admitted to our hospital presenting with appetite loss and body weight loss. He was diagnosed to have an inoperable gastric small cell carcinoma with severe lymph node metastases and left adrenal gland metastasis. Chemotherapy with TS-1/paclitaxel, cisplatin/irinotecan and cisplatin/etoposide was sequentially performed. Primary and metastatic foci had obviously diminished. Eighteen months after the initial therapy, he had dysarthrosis and multiple brain metastases were found. Metastatic foci were decreased and his symptom was improved by successful radiotherapy. We conclude that chemotherapy and radiotherapy are effective for primary and metastatic lesions of gastric small cell carcinoma.

Laparoscopy-assisted distal gastrectomy for early gastric cancer poses few limitations for selected elderly patients: a single-center experience.

BACKGROUND: The safety and efficacy of laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer have been demonstrated in clinical studies. The aim of this study was to clarify the safety and efficacy of LADG in patients ≥80 years of age with early gastric cancer, an American Society of Anesthesiologists (ASA) classification of 1-2, and a performance status (PS) of 0-1. CASE PRESENTATION: From April 2009 to July 2011, 12 elderly patients aged ≥80 years and 43 younger patients underwent LADG for early gastric cancer. Seven of the 55 patients underwent LADG and simultaneous surgery including surgery for colorectal cancer, cholecystectomy, or other conditions. Forty-eight of the 55 patients who underwent only LADG were studied. Demographics and postoperative outcomes were compared. RESULTS: The postoperative complication rate, time to first ambulation, time to first flatus, time to first fluid intake, and postoperative hospital stay were similar in these two groups. Nutritional status as assessed by body weight, serum albumin, and total protein at 1 and 3 months after surgery was also similar in these two groups. CONCLUSIONS: Postoperative outcomes were acceptable in the elderly patients included in the study. LADG for early gastric cancer is a safe and effective treatment in elderly patients aged ≥80 years with an ASA status of 1-2 and PS of 0-1.

A novel surgical technique for bleeding duodenal varices after failure of balloon-occluded retrograde transvenous obliteration: a case report.

BACKGROUND: Duodenal varices are a low-frequency cause of gastrointestinal bleeding; however, greater than 40 % mortality has been reported after the initial bleeding episode. CASE PRESENTATION: This report describes a 72-year-old woman with bleeding duodenal varices treated by surgery after failure of balloon-occluded retrograde transvenous obliteration (B-RTO). The patient presented with profuse melena. Emergent upper endoscopy was immediately performed, and bleeding duodenal varices in the second portion of the duodenum were seen. Endoscopic band ligation was attempted first followed by B-RTO; however, the combined procedures failed. Laparotomy under general anesthesia was then performed, and the venous collaterals were cannulated using an 18-gauge needle. Following intraoperative angiography, the venous collateral was ligated on the peripheral side of the needle entry point, and ethanolamine oleate was injected into the afferent collateral vessel. Endoscopic examination on postoperative day 4 showed embolization of the duodenal varices. The patient was discharged on postoperative day 11. CONCLUSIONS: This technique is simple and effective, and we believe it is a potential alternative surgical treatment for duodenal varices with portal hypertension.

Significance of ERK nitration in portal hypertensive gastropathy and its therapeutic implications.

Portal hypertensive (PHT) gastric mucosa increases susceptibility to injury and delayed mucosal healing. It is possible that nitration of ERK by peroxynitrite might alter MAPK (ERK) signaling in PHT gastric mucosa, leading to delayed mucosal healing, since excessive nitric oxide production is implicated in PHT gastric mucosa and MAPK (ERK) signaling induces cell proliferation and leads to gastric mucosal healing in response to injury. Portal hypertension was produced by staged portal vein ligation, and sham-operation (SO) rats served as controls. Lipid peroxide (LPO) and nitrotyrosine increased significantly in PHT gastric mucosa compared with SO rats. ERK activation was impaired in PHT gastric mucosa in response to ethanol injury, whereas no significant difference in the phosphorylation of MEK, an upstream molecule of ERK, was seen between the two groups. The nitration of ERK by peroxynitrite, as detected by the coimmunoprecipitation of ERK and nitrotyrosine, was significantly enhanced in PHT gastric mucosa. Administration of rebamipide, a gastroprotective drug that acts as an oxygen-derived free radical scavenger, significantly decreased LPO and nitrotyrosine as well as the nitration of ERK by peroxynitrite in PHT gastric mucosa, therefore normalizing ERK activation and restoring the gastric mucosal healing response to ethanol injury. Enhanced nitration of ERK by peroxynitrite is involved in the impaired MAPK (ERK) signaling in PHT gastric mucosa. These findings demonstrate a new molecular mechanism in which PHT gastric mucosa is predisposed to injury and impaired healing.