Acute complicated type B aortic dissection during the New York City COVID-19 surge.

The impact of the coronavirus disease 2019 (COVID-19) pandemic in New York City (NYC) is dramatic. COVID-19 cases surged, hospitals expanded to meet capacity, and NYC remains the global epicenter of this pandemic. During this unprecedented time, a young woman with known Marfan syndrome presented with an acute complicated type B aortic dissection to our Aortic Center. Using the provisional extension to induce a complete attachment technique, we treated this patient and quickly discharged her the next day to decrease the risk of COVID-19 infection. Her progress was monitored using frequent phone calls and one office visit at two weeks.

The treatment of tuberculous aortic pseudoaneurysm.

OBJECTIVE: Our aim was to compare the outcomes of tuberculous aortic aneurysms treated with endovascular aortic repair (TEVAR) or open surgery. METHODS: An electronic search of the National Library of Medicine PubMed database for tuberculous aortic aneurysm was performed between January 1998 through December 2017. Cases were screened for completeness of information and outcomes were recorded and analyzed. RESULTS: A total of 56 studies were reviewed, with 61 (20 TEVAR, 41 open surgical repair) having adequate case details and follow-up. The in-hospital/30-day mortality was 0% (0 out of 20) in the TEVAR group and 7% (three out of 41) in the open surgery group (P = .54). Overall mortality was 5% (1/20) in the TEVAR group and 10% (4/41) in the open surgery group (P = .53). Two-year survival and freedom from aneurysm recurrence were comparable in the two groups, P = .45 and P = .94, respectively. One patient in the TEVAR group and one patient in the open surgery group died due to a rupture of a recurrent aortic aneurysm 16 and 28 months after surgery, respectively. CONCLUSIONS: TEVAR and anti-tuberculosis (TB) medications are reasonable initial treatment options for tuberculous aortic aneurysm especially in high-risk patients; however, careful follow-up is necessary.

A case of sarcoidosis with severe acute renal failure requiring dialysis.

We report here a 79-year-old male having sarcoidosis without presentation of typical findings, such as respiratory symptoms, ocular signs, or skin lesions. Two weeks prior to admission to our hospital, he presented to a different hospital with acute renal failure, with blood urea nitrogen (BUN) and serum creatinine (Cr) levels of 67.9 mg/dl and 7.97 mg/dl, respectively, and was initiated on hemodialysis. The patient also exhibited fever, severe anorexia, and fatigue. We initially experienced difficulty in performing kidney biopsy due to a thrombocytopenia complication and severe general debility. Tuberculosis and other malignancies were not found. However, bone marrow biopsy revealed noncaseating granuloma with multinucleated giant cells, and the patient's serum angiotensin converting enzyme (ACE) level was slightly elevated at 24.3 U/l. We informed the patient and his family of the risk of a kidney biopsy and subsequently received informed consent for the procedure. The biopsy showed many epitheloid granulomas with multinucleated giant cells in the interstitium, from which we diagnosed sarcoidosis. The thrombocytopenia was subsequently found to be due to heparin-induced thrombocytopenia (HIT). After administering 20 mg/day of oral prednisolone, the patient's general condition improved rapidly. Therefore, it is important to take sarcoidosis into account as a differential diagnosis of acute renal failure, and kidney biopsy offers useful information in these cases.

A pathological complete response after immunotherapy with pembrolizumab for distal duodenal adenocarcinoma caused by Lynch syndrome: a case report.

Primary adenocarcinoma of the duodenum is a rare neoplasm that is often microsatellite instability-high (MSI-H). Pembrolizumab, a monoclonal antibody, has been recently approved in Japan for treatment of MSI-H solid tumors. Lynch syndrome is a frequent hereditary cancer predisposition syndrome. It is linked to an increased risk of various types of cancer, including colorectal and endometrial cancer, and is closely related to MSI-H. We present the case of a 55-year-old woman who was diagnosed with duodenal cancer. Biopsy findings revealed MSI-H, and pembrolizumab therapy was initiated because the tumor was in contact with the left renal vein and had metastasized to the mesenteric lymph nodes of the small intestine. Subsequently, after completing two courses of pembrolizumab therapy, the patient developed duodenal stenosis and underwent surgery. Pathological analysis of the resected specimen revealed no evidence of malignancy. Given the patient's previous cancer history and the occurrence of cancer in close relatives, genetic testing of peripheral blood was performed, which revealed the diagnosis of Lynch syndrome. Furthermore, the variant responsible for Lynch syndrome was found to be a mutation of NM_000251.3:c.211 + 1G > C in MSH2.

Prognostic Impact of Lymphocyte-C-Reactive Protein Ratio in Patients Who Underwent Surgical Resection for Hepatocellular Carcinoma.

BACKGROUND: Systemic inflammation-related factors, either independently or in combination, are recognized as prognostic factors for various cancers. The ratio of lymphocyte count to C-reactive protein concentration (lymphocyte-CRP ratio; LCR) is a recently identified prognostic marker for several cancers. Here, we examined the prognostic value of the LCR in patients with hepatocellular carcinoma (HCC). METHODS: This was a single-center retrospective study of patients who underwent surgical resection for HCC between 2004 and 2017. Patients were divided into high- and low-LCR status groups, and the relationships between LCR status, prognosis, and other clinicopathological characteristics were analyzed. RESULTS: A total of 454 patients with HCC were enrolled and assigned to the high- (n=245) or low- (n=209) LCR groups. Compared with the high-LCR group, patients in the low-LCR group had a significantly lower serum albumin level (median 4.1 vs. 3.9 g/dL, P <0.0001), lower platelet count (median 14.0 vs. 12.0 ×104/µL, P=0.0468), lower prothrombin time (median 93.2 vs. 89.6 %, P=0.0006), and larger tumor size (median 2.3 vs. 2.5 cm, P=0.0056). Patients with low-LCR status had significantly worse outcomes of overall survival and disease-free survival than patients with high-LCR status (P=0.0003 and P=0.0069, respectively). Low-LCR status was significantly associated with worse overall survival in multivariate analysis (hazard ratio 1.57, 95% confidence interval 1.14-2.17, P=0.0058). CONCLUSIONS: Low-LCR status may predict worse outcomes in patients with HCC. Measurement of LCR is routine and can easily be applied for risk stratification in the assessment of patients with HCC.

Amplatzer Vascular Plug for Complicated Residual DeBakey Type 1 Aortic Dissection in the Aortic Arch.

Surgical treatment of acute DeBakey type I aortic dissection does not address the entire aorta, which can leave anatomically complex residual aortic dissection in the aortic arch and descending aorta. Open repair has been the standard treatment for this pathology. When the lesions are located in the aortic arch, re-do total arch replacement needs to be performed. Plug placement to close small entry tears in the aortic arch has been reported. This article reports about a 79-year-old man who underwent hemiarch replacement for acute DeBakey type I aortic dissection. One year later, his proximal descending aorta dilated to 6.3 cm. The patient was treated with Amplatzer plug in the false lumen, and a stent graft was placed in the true lumen. Follow-up computed tomography scan confirmed complete thrombosis of the false lumen in the descending aorta which had decreased from 6.3 to 4.0 cm. Plug placement in the false lumen in the aortic arch is a potential treatment strategy for anatomically complex residual aortic dissection to induce thrombosis of the false lumen and encourage remodeling.

A Novel Case of Spontaneous Coronary Artery Dissection During Cabergoline Therapy for Prolactinoma.

We present a case of spontaneous coronary artery dissection associated with cabergoline treatment for prolactinoma. A 31-year-old woman with history of hypertension and prolactinoma, treated with cabergoline, presented with chest pain. She had non-ST-segment elevation myocardial infarction with double vessel coronary artery dissection and was treated with coronary artery bypass grafting. (Level of Difficulty: Beginner.).

Post-transplant inflow modulation for early allograft dysfunction after living donor liver transplantation.

BACKGROUND: To treat small-for-size syndrome (SFSS) after living donor liver transplantation (LDLT), many procedures were described for portal flow modulation before, during, or after transplantation. The selection of the procedure as well as the best timing remains controversial. CASE PRESENTATION: A 43-year-old female with end-stage liver disease underwent LDLT with extended left with caudate lobe graft from her donor who was her 41-year-old brother (graft volume/standard liver volume (GV/SLV), 35.7%; graft to recipient weight ratio (GRWR), 0.67%). During the surgery, splenectomy could not be performed owing to severe peri-splenic adhesions to avoid the ruined bleedings. The splenic artery ligation was not also completely done because it was dorsal to the pancreas and difficult to be approached. Finally, adequate portal vein (PV) inflow was confirmed after portal venous thrombectomy. As having post-transplant optional procedures that are accessible for PV flow modulation, any other procedures for PV modulation during LDLT were not done until the postoperative assessment of the graft function and PV flow for possible postoperative modulation of the portal flow accordingly. Postoperative PV flow kept as high as 30 cm/s. By the end of the 1st week, there was a progressive deterioration of the total bilirubin profile (peak as 19.4 mg/dL) and ascitic fluid amount exceeded 1000 mL/day. Therefore, splenic artery embolization was done effectively and safely on the 10th postoperative day (POD) to reverse early allograft dysfunction as PV flow significantly decreased to keep within 20 cm/s and serum total bilirubin levels gradually declined with decreased amounts of ascites below 500 mL on POD 11 and thereafter. The patient was discharged on POD 28 with good condition. CONCLUSIONS: SFSS can be prevented or reversed by the portal inflow modulation, even by post-transplant procedure. This case emphasizes that keeping accessible angiographic treatment options for PV modulation, such as splenic artery embolization, after LDLT is quite feasible.

Correction to: Post-transplant inflow modulation for early allograft dysfunction after living donor liver transplantation.

An amendment to this paper has been published and can be accessed via the original article.

Mixed adenoneuroendocrine carcinoma of the distal bile duct: a case report.

BACKGROUND: Mixed adenoneuroendocrine carcinoma (MANEC) of the common bile duct (CBD) is very rare, with only 10 reported cases. Here, we report a case of MANEC of the distal bile duct (DBD) that was surgically resected under a diagnosis of cholangiocarcinoma (CCA). CASE PRESENTATION: A 60-year-old male had epigastric pain and was admitted to our hospital for the treatment of a suspected CBD stone. Upon admission, laboratory findings revealed elevated hepatobiliary enzymes including serum aspartate aminotransferase, serum alanine aminotransferase, serum glutamyltransferase, and serum alkaline phosphatase. Both carcinoembryonic antigen and carbohydrate antigen 19-9 were negative. Computed tomography (CT) showed dilation of the CBD. Endoscopic retrograde cholangiopancreatography (ERCP) showed circumferential stenosis and a 5-mm elevated lesion in the DBD. Brush cytology showed atypical ductal cells, indicating adenocarcinoma (AC) of the DBD. Under a diagnosis of CCA of the DBD, a subtotal stomach-preserving pancreaticoduodenectomy was performed. Neither peritoneal dissemination nor lymph node metastasis was found. Microscopically, the lesion was seen to be composed of predominantly well-differentiated tubular AC in the superficial layer of the tumor, admixed with neuroendocrine carcinoma (NEC) in the deeper portion, indicating a diagnosis of MANEC of the DBD. After immunohistochemical staining, NEC components were positive for synaptophysin and CD56 and were for SSTR2, SSTR5, and mammalian target of rapamycin (mTOR). Three months postsurgery, postoperative adjuvant chemotherapy with S-1 was started. More than 3 years postsurgery, he is alive without recurrence. CONCLUSIONS: MANEC is highly malignant, progresses rapidly, and has a poor prognosis. Preoperative diagnosis is difficult; therefore, identifying NEC components by immunohistochemical staining using resected specimens is important.

Large surgically resected leiomyosarcoma of the liver: a case report.

BACKGROUND: Primary hepatic leiomyosarcoma (PHL) is an extremely rare type of tumor. We herein report a case of a large surgically resected leiomyosarcoma of the liver. CASE PRESENTATION: A 69-year-old man with a feeling of epigastric compression was referred for examination of an abdominal mass. He had no history of liver disease or alcohol abuse. Liver function tests indicated Child-Pugh class A. Tumor markers were negative. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a relatively well-contrasted 12 × 11 × 8 cm tumor with well-defined boundary replacing the lateral segment of the liver alongside multiple intrahepatic metastases. Several nodules up to 12 mm were found in both lungs, suggestive of metastasis. SUVmax of the liver mass and lung tumor in positron emission tomography were 10.4 and 1.5, respectively. Hepatocellular carcinoma was primarily suspected. Lateral segmentectomy of the liver was performed to confirm diagnosis and prevent tumor rupture. Macroscopically, the lateral segment of the liver had been replaced by a lobular or multinodular tumor with a maximum diameter of 15 cm. In pathological findings, the tumor consisted of bundle-like proliferation of complicated banding spindle-like cells with clear cytoplasm, accompanied by storiform pattern and compressed blood vessels. Nuclear fission images were observed in 8/10 HPF. Partial necrosis was present, with associated venous invasion and intrahepatic metastasis. Immunohistochemical staining for tumor cells revealed desmin, α-smooth muscle actin (αSMA), and h-caldesmon were all positive, informing a final diagnosis of PHL. The postoperative course was uneventful, and he was discharged on the 12th postoperative day. CONCLUSIONS: PHL is a rare malignant disease with relatively poor prognosis. To confirm a diagnosis of PHL, immunohistochemical analysis as well as histopathological findings is important. The preferred treatment is surgical resection, sometimes in combination with adjuvant chemotherapy and radiotherapy. Further studies are needed to elucidate and better understand this uncommon clinical entity.

Hepatic resection for recurrent hepatocellular carcinoma during pregnancy: a case report.

BACKGROUND: Hepatocellular carcinoma (HCC) during pregnancy is extremely rare. Treatment strategies for cancers detected during pregnancy have been controversial. We herein report a case of recurrent HCC detected at 20 weeks of pregnancy, which subsequently prompted hepatic resection after abortion. CASE PRESENTATION: A 36-year-old woman underwent laparoscopic partial hepatectomy for HCC (20 mm in diameter) in segment 5 of the liver during follow-up after being determined as a hepatitis B virus carrier two and a half years ago. Post-surgery follow-up abdominal ultrasonography revealed a 36-mm tumor in segment 7 of the liver. Abdominal contrast-enhanced computed tomography revealed a well-enhanced tumor with a 40-mm diameter in segment 7 adjacent to the inferior vena cava and right hepatic vein, suggesting HCC recurrence. Laboratory data revealed total bilirubin (0.4 mg/dL), aspartate aminotransferase (28 IU/L), alanine aminotransferase (30 IU/L), glutamyltransferase (16 IU/L), prothrombin time (115.3%), and indocyanine green retention rate at 15 min (7.0%). α-Fetoprotein (AFP) (12,371.5 ng/mL; normal range < 10 ng/mL) and PIVKA-II (208 mAU/mL; normal range < 40 mAU/mL) were both significantly elevated. After discussions with a cancer board consisting of experts from the departments of gastroenterology, obstetrics and gynecology, and surgery, as well as obtaining appropriate informed consent from the patient and her family, we decided to perform a hepatic resection after abortion. Subsequently, abortion surgery was performed at 21 weeks and 2 days of pregnancy. After 6 days, subsegmentectomy of liver segment 7 was performed under general and epidural anesthesia, with a pathological diagnosis which was moderately differentiated HCC being established. Given the good postoperative course, without particular complications, the patient was subsequently discharged 10 days after the operation. Approximately 2 years after the surgery, the patient remains alive without recurrence, while both AFP and PIVKA-II were within normal limits. CONCLUSIONS: Treatment strategies for HCC detected during pregnancy remain controversial. As such, decisions should be made based on HCC growth and fetal maturity after thorough multidisciplinary team discussions and obtaining appropriate informed consent from the patient and her family.

Cardiac resynchronization therapy for ischemic myopathy.

We performed coronary artery grafting, mitral valve plasty, and tricuspid plasty in a 75-year-old man who had double-vessel coronary disease and moderate mitral and tricuspid insufficiency. Preoperative transthoracic echocardiography revealed an ejection fraction of 34% and dyssynchronous wall motion of the septum and free wall. We placed pacing leads on the right ventricular outlet and posterior left ventricular wall for cardiac resynchronization therapy. The dyssynchrony disappeared postoperatively and the New York Heart Association functional class improved from IV to I.

Hepatic organoid formation in collagen sponge of cells isolated from human liver tissues.

We examined whether small hepatocytes (SHs), which are hepatic progenitor cells, could be isolated from a normal human liver and whether human hepatic cells could form hepatic organoids in a collagen sponge. Normal liver tissues were obtained from resected specimens from nine patients who underwent hepatic resection. Isolated hepatic cells were plated on dishes and a collagen sponge. More than 1 month later, SH-like cells appeared and proliferated on the dishes, whereas cell aggregates were formed in the sponge and showed characteristic tissue architecture: columnar and/or cuboidal epithelial cells lined the surface of the sponge. Clusters of epithelial cells with a large cytoplasm and ductular structures were observed under the lining cells. The lining and ductular cells were positive for cytokeratins 7 and 19, which indicated they were biliary epithelial cells (BECs), and the epithelial cells forming clusters were positive for the anti-human hepatocyte antibody, identifying them as hepatocytes. Some lining cells were positive for both the hepatic marker and the BEC markers. The cells in the collagen sponge actively proliferated and the hepatocytes excreted albumin into the medium. Thus, hepatic organoids could be reconstructed in a collagen sponge by normal human liver cells.

Tumor necrosis factor-alpha and interleukin-6 reduce bile canalicular contractions of rat hepatocytes.

BACKGROUND: Surgeons sometimes encounter hyperbilirubinemia without mechanical obstruction of the biliary tree postoperatively. Many of these patients have bacterial infections and endotoxemia. Kupffer's cells stimulated by endotoxin secrete inflammatory cytokines such as tumor necrosis factor (TNF)-alpha and interleukin (IL)-6. We hypothesized that TNF-alpha and IL-6 might be involved in the pathogenesis of hyperbilirubinemia. METHODS: Effects of TNF-alpha and IL-6 on the contractions of bile canaliculi (BC) of rat hepatocyte couplets were examined and time-lapse images using phase-contrast microscopy were taken. Bile was collected from rats treated with or without the cytokines. The livers, perfused with lanthanum after the injection of cytokines, were examined ultrastructurally using electron microscopy. RESULTS: The number of BC contractions decreased in the couplets treated with both cytokines. The rapid movement of a droplet from BC was observed at the intercellular space of the hepatocyte couplet treated with TNF-alpha. Systolic blood pressure and hepatic tissue blood flow of rats injected with TNF-alpha were not changed, whereas the hepatic tissue blood flow of rats treated with IL-6 decreased (Dunnett test, P <.05). Bile secretion was reduced in both groups of rats (Dunnett test, P <.05). In rats treated with TNF-alpha the total serum bile acid concentration increased and lanthanum temporarily accumulated in BC. CONCLUSIONS: These results suggest that TNF-alpha and IL-6 may reduce BC contractions and thereby decrease bile flow.

A simple and safe procedure to repair rectal prolapse perineally using stapling devices.

Rectal prolapses are not life-threatening, however the bleeding and fecal incontinence associated with them significantly erode quality of life and can cause concern among patients' caregivers in nursing homes. Many procedures have been reported that repair rectal prolapses, and the procedure used depends on the severity of the prolapse; however, the treatments are yet to be established. Here we report a simple and safe procedure to repair rectal prolapse perineally using stapling devices. We performed this procedure on 5 patients within a short time. All patients were followed up for over 24 months and none had any recurrences of their rectal prolapses. No complications occurred during the operations and postoperative periods. Most patients who have prolapses are elderly and fragile, so the treatment must be easy, safe, and rapid. While rectal prolapse is not life-threatening, the goal of treatment is to alleviate its symptoms. The procedure we describe is consistent with this concept. We suggest that this procedure, which uses surgical stapling devices, might be a better option for the treatment of complete rectal prolapse. We will continue to surgically correct complete rectal prolapses and investigate the long-term outcomes of the procedure.