Surgical Treatment for Encapsulating Peritoneal Sclerosis: 24 Years' Experience.

BACKGROUND: Encapsulating peritoneal sclerosis (EPS) is a serious complication of long-term peritoneal dialysis. The mortality rate for EPS is high, primarily due to complications related to bowel obstruction. Surgery was previously contraindicated; however, surgical enterolysis is performed for patients in whom bowel obstruction fails to improve. METHODS: This was a retrospective observational study of patients with EPS who received surgical intervention at a single center between November 1993 and October 2017. The severity of intestine damage was characterized by grade-3 peritoneal calcification on abdominal computed tomography (CT) scan and degeneration of the small intestinal wall in surgery. RESULTS: Two-hundred and forty-three patients with EPS opted for surgery. Among them, 58 had recurrence and required re-surgery; a total of 318 EPS surgeries were performed. Death was related to EPS in 61 patients (25.1%), of whom 15 died postoperatively. Sixty-seven patients (27.6%) died from other causes. The actuarial survival rates at 1, 2, 3, 5, and 8 years after EPS diagnosis were 91%, 83%, 77%, 66%, and 53% respectively. The 50% actuarial survival points after EPS diagnosis and surgery were 104 months and 85 months, respectively. Peritoneal calcification and small intestinal wall degeneration grading showed significant association with the mortality curve for EPS-related death. CONCLUSION: Excellent outcomes for EPS are achieved with surgery. The degree of peritoneal deterioration affected the clinical outcomes. Currently, EPS is no longer recognized as a fatal complication.

Sessile serrated adenoma/polyp leading to acute appendicitis with multiple pyogenic liver abscesses: A case report.

INTRODUCTION: Although appendicitis is a common disease, appendicitis concurrent with liver abscesses and sessile serrated adenoma/polyp (SSA/P) is rare. PRESENTATION OF CASE: A 69-year-old man presented with symptoms of abdominal pain and fever. Computed tomography (CT) revealed multiple liver abscesses and an enlarged appendix with a pseudotumoral appearance, which suggested acute appendicitis. In the emergency operation, ileocecal resection was performed for the perforated appendicitis with an inflammatory mass in the ileocecum. On macroscopic examination, the torose lesion was localized at next to the appendiceal orifice. The tumor was diagnosed as SSA/P based on the microscopic finding. The postoperative course was uneventful, and the liver abscesses were cured by antibiotic therapy. The patient was discharged 17days after the surgery. DISCUSSION: In this case, SSA/P localization at next to the appendiceal orifice was suggested as the cause of the perforated appendicitis with multiple liver abscesses. The patient was successfully treated with a combination of surgery and antibiotic therapy. CONCLUSION: This is the first reported case of a patient with SSA/P that led to acute appendicitis with multiple pyogenic liver abscesses.

De Garengeot hernia with perforated appendicitis and a groin subcutaneous abscess: A case report.

INTRODUCTION: De Garengeot hernia is rare. Although previous reports have suggested various surgical options according to patient condition, comorbidities, surgeon preference, and clinical findings during surgery, a treatment strategy has not been established. PRESENTATION OF CASE: An 81-year-old woman presented with an irreducible tender mass that was subsequently diagnosed as an incarcerated femoral hernia with a subcutaneous abscess in the right groin. Intraoperative findings revealed a necrotic and perforated appendix strangulated by the femoral ring for which an appendectomy and herniorrhaphy was performed concurrently through the hernia sac. The subcutaneous abscess cavity was washed thoroughly and a drainage tube was placed within it. The patient recovered uneventfully. DISCUSSION: We suggest that the approach through the inguinal incision in both appendectomy and herniorrhaphy with drainage may be useful in avoiding intra-abdominal contamination in cases of de Garengeot hernia with subcutaneous abscess. CONCLUSION: Here, we described a case of de Garengeot hernia with a subcutaneous abscess in the groin. Clinicians should consider de Garengeot hernia in patients with a groin hernia, make an early diagnosis, and promptly provide surgical treatment to reduce the risk of complications.

Acute Cholecystitis with Significantly Elevated Levels of Serum Carbohydrate Antigen 19-9.

Serum carbohydrate antigen 19-9 (CA 19-9), a marker of malignant tumors, is generally slightly elevated in benign conditions. We report a case of acute cholecystitis with a significantly elevated level of serum CA 19-9 based on positron emission tomography (PET)-computed tomography (CT) findings. A 65-year-old woman presented with abdominal pain and fever. A CT image revealed an enlarged gallbladder without tumor shadows. The C-reactive protein (CRP) level was elevated to 7.66 mg/dl. Moreover, the serum CA 19-9 level was significantly elevated to 19,392 U/ml. We started antibiotic treatment, because we suspected acute cholecystitis, but still, we could not ignore the possible presence of malignant tumors. After 11 days of antibiotic treatment, serum CRP and CA 19-9 levels decreased to 0.11 mg/dl and 1,049 U/ml, respectively. There was an accumulation of fluorine 18-labeled fluorodeoxyglucose (maximum standardized uptake value, 9.3) without tumor shadows in the liver, near the gallbladder, on the PET-CT examination. We considered the possibility that the inflammation had spread from the gallbladder to the liver, made a diagnosis of acute cholecystitis, and performed a cholecystectomy 33 days after treatment initiation. The serum CA 19-9 level decreased to 45 U/ml after the surgery. One year after the surgery, the patient was alive, and the serum CA 19-9 level was 34 U/ml. Acute cholecystitis with a significantly high elevation of the serum CA 19-9 level is rare. In such cases, it is important to confirm the change in the serum CA 19-9 level over time after antibiotic treatment and perform imaging studies to distinguish between inflammation and malignancy.

De novo renal cell carcinoma in a kidney allograft 20 years after transplant.

Renal cell carcinoma (RCC) in a kidney allograft is rare. We report the successful diagnosis and treatment of a de novo RCC in a nonfunctioning kidney transplant 20 years after engraftment. A 54-year-old man received a kidney transplant from his mother when he was 34 years old. After 10 years, chronic rejection resulted in graft failure, and the patient became hemodialysis-dependent. Intravenous contrast-enhanced computed tomography (CT) for the evaluation of gastrointestinal symptoms revealed a solid 13 mm tumor in the kidney graft. The tumor was confirmed on ultrasound examination. This tumor had not been detected on a surveillance noncontrast CT scan. Needle biopsy showed that the tumor was an RCC. Allograft nephrectomy was performed. Pathological examination showed that the tumor was a Fuhrman Grade 2 RCC. XY-fluorescence hybridization analysis of the RCC showed that the tumor cells were of donor origin. One year after the surgery, the patient is alive and has no evidence of tumor recurrence. Regardless of whether a kidney transplant is functioning, it should periodically be imaged for RCC throughout the recipient's lifetime. In our experience, ultrasonography or CT with intravenous contrast is better than CT without contrast for the detection of tumor in a nonfunctioning kidney transplant.

Seventeen years' experience of surgical options for encapsulating peritoneal sclerosis.

Encapsulating peritoneal sclerosis (EPS) is a serious complication of long-term peritoneal dialysis (PD). The mortality rate for EPS has been high, primarily because of complications related to bowel obstruction. However recent advances in clinical research have established the pathogenesis and course of the condition and a treatment strategy. The final therapeutic option for EPS is surgical enterolysis, and we have performed 239 surgical procedures in 181 patients and observed favorable outcomes. Of 181 patients opting for surgery 64 (35.40%) died. Death was related to EPS in 33 patients (18.2%), including 14 who died postoperatively. The overall survival rate at 1, 2, 3, 5, and 8 years after diagnosis was 93%, 83%, 78%, 71%, and 60% respectively. The survival rate for EPS-related death at 1, 2, 3, 5, and 8 years after diagnosis was 95%, 90%, 87%, 81%, and 74% respectively. Median survival after diagnosis, considering death from any cause and death from EPS, was 43.9 months and 35.7 months respectively. In conclusion, we present favorable outcomes with EPS surgery in 181 patients encountered over a period of 17years. These data reconfirm that surgical treatment is essential for EPS patients. Encapsulating peritoneal sclerosis may no longer be a fatal complication and can be improved with accurate diagnosis and treatment.

A case of encapsulating peritoneal sclerosis suspected to result from the use of icodextrin peritoneal solution.

Encapsulating peritoneal sclerosis (EPS) is an intestinal obstruction syndrome in which peritoneal deterioration and intraperitoneal inflammation result in intestinal adhesions, which are covered with a fibrin capsule and which cause bowel obstruction. Here, we report the case of a patient with EPS suspected to result from the use of icodextrin peritoneal solution. In this patient, peritoneal permeability to high molecular weight solutes and effluent interleukin-6 (IL-6) levels increased after initiation on-to icodextrin solution. The patient developed symptoms of intestinal obstruction accompanied by intestinal edema 30 months after the start of icodextrin and after a peritoneal dialysis (PD) duration of 78 months. He was then diagnosed as being in a pre-EPS state. The use of icodextrin solution was discontinued, and the symptoms of intestinal obstruction improved after corticosteroid administration. Subsequently, he was managed on a combination of PD using glucose solution low in glucose degradation products and of twice-weekly hemodialysis, but he showed enhanced peritoneal permeability and increases in effluent IL-6. After a PD period of 98 months, severe symptoms of intestinal obstruction developed, and enterolysis was performed. The degeneration of the intestinal wall itself was slight, and the adhesions between the capsule and intestinal surface could be readily removed. In this patient, the degree of peritoneal deterioration and capsule formation differed from that of typical EPS. These findings suggest the promotion of capsule formation by icodextrin solution and the involvement of certain inflammatory reactions.

Surgical techniques for prevention of recurrence after total enterolysis in encapsulating peritoneal sclerosis.

We performed total enterolysis in 130 patients with encapsulating peritoneal sclerosis (EPS) between 1993 and 2007. The postoperative survival rate was 93.1%. However, 33 of the patients (25.4%) required additional surgery for recurrent bowel obstruction. To prevent recurrent bowel obstruction, we investigated various techniques following total enterolysis. In 7 patients, we employed the splinting method, in which the intestinal tract is fixed for 1 week after surgery by the insertion of a long intestinal tube. In 3 of the patients, recurrence was detected within 6 months after surgery. We therefore ceased using splinting. From April 2007, we performed the Noble plication procedure, in which intestine-to-intestine suturing is performed to prevent recurrent bowel obstruction, in 17 patients. None of those patients experienced a recurrence during 8 months of follow-up. In 7 patients showing marked calcification or repeated recurrence, we performed anastomosis of the superior jejunum and transverse colon after adhesiotomy. In 5 patients, excluding 2 with recurrence, improvement was achieved. Total enterolysis for EPS relieved bowel obstruction in most patients. However, after surgery, bowel obstruction recurred in some cases. Thus, strategies to reduce recurrence should be established. Currently, we use total enterolysis and Noble plication as our standard techniques. Further basic and clinical studies regarding EPS prevention and treatment should be conducted.

Recommendation of the surgical option for treatment of encapsulating peritoneal sclerosis.

Encapsulating peritoneal sclerosis (EPS) is an intestinal obstruction syndrome in which peritoneal deterioration and intraperitoneal inflammation result in intestinal adhesions, which are covered with a fibrin capsule and cause bowel obstruction. The widespread use of peritoneal dialysis (PD) has been associated with an increase in the number of patients with this life-threatening complication. For this reason, some negative comments have been made about PD therapy. However, recent clinical studies have elucidated the pathogenesis of EPS and proposed therapeutic strategies. Currently, these facts are known: EPS occurs in 2.5% of all patients (3.18/1000 patient-years). A longer duration of PD is associated with a higher incidence of EPS and a poorer prognosis, indicating the involvement of peritoneal deterioration in the development of EPS. Development of EPS involves some kind of infection. Development of EPS frequently occurs after PD withdrawal and catheter removal. Peritoneal lavage after PD withdrawal delays, but cannot prevent the development of EPS. Timely administration of steroids is effective. Surgical adhesiolysis is the optimal treatment to relieve bowel obstructions, but does not exclude the potential for re-adhesions, requiring various ingenious gastro-intestinal surgical techniques.

Prognosis in patients with hepatocellular carcinoma correlates to mutations of p53 and/or hMSH2 genes.

Association of gene alterations and prognosis has not fully been elucidated in hepatocellular carcinoma (HCC). To clarify the relationship between p53 and hMSH2 mutations and prognosis, we analysed these mutations in 83 HCC cases and assessed their association with various clinicopathological factors. The 3-year disease-free survival (DFS) or overall survival (OS) rates in HCC patients with p53 mutation and p53 wild/hMSH2 mutation significantly decreased compared with those without these mutations (14.3% and 37.5% versus 67.5% for DFS; 35.7% and 50.0% versus 96.4% for OS, respectively). In the multivariate analysis, categories by p53 and hMSH2 mutation status, and liver cirrhosis demonstrated statistical significances for DFS and OS. Moreover, the frequency of patients with p53 and/or hMSH2 mutations in intrahepatic metastasis (75.0%) was significantly higher than that in multicentric occurrence (14.3%). Thus, p53 and hMSH2 mutations will be useful for identifying subsets of HCC patients with poor prognosis.

Studies on post-transplant dyslipidemia in kidney transplant patients.

This study was performed to retrospectively compare changes in the levels of total cholesterol, non-HDL cholesterol, triglycerides, and immunosuppressive drugs, cyclosporine A and steroids in patients with living-relation renal transplants with those from non-heart-beating donors. We experienced 11 cases of kidney transplants from non-heart-beating donors during the period from April 1995 to May 2003. We evaluated 13 cases of kidney transplants from living-relation donors during the same period. The immunosuppressants used included mainly cyclosporine A as well as mycophenolate mofetil or azathioprine, steroid and ALG, or basiliximab. Over-night fasting lipids (total cholesterol, triglycerides and HDL cholesterol) were studied before renal transplantation and repeated after renal transplantation at 1, 3, 6 and 12 months. The levels of total cholesterol and triglycerides remained in the normal range before transplantation. However, the levels of total cholesterol increased siginificantly 1 and 3 months after transplantation from non-heart-beating donors and remained at higher levels up to 12 months after transplantation. A similar pattern in the levels of triglycerides was observed. The levels of HDL cholesterol remained unchanged and stayed in the normal range before and 1, 3, 6, and 12 months after transplantation from non-heart-beating donors. On the other hand, significant increases in non-HDL cholesterol were observed 3 and 6 months after transplantation from non-heart-beating donors. After transplantation from living-relation donors, levels of total cholesterol, triglycerides, and non-HDL cholesterol remained unchanged and remained in the normal range up to 12 months after transplantation. Although there were no significant differences in the total dosage of cyclosporine A between the patients with living-relation donors and those with non-heart-beating donors, a significant increase in the total dosage of methylprednisolone was observed in patients with non-heart-beating donors compared with those in the patients with living-relation donors. Renal function recovery in patients with living-relation donors was better than in those with non-heart-beating donors. These results may suggest that significant increases in total cholesterol, especially non-HDL cholesterol and triglycerides, were probably partly due to an increased use of immunosuppressants, steroids. It is necessary to aggressively control post-transplant hyperlipidemia and important to reduce or withdraw steroids in the selected, low-risk recipients as early as possible from the viewpoint of preventing post-transplant hyperlipidemia.

Studies on eleven kidney transplants from non-heart-beating donors.

This study was performed to analyze postoperative courses and complications, retrospectively, following transplants from non-heart-beating donors and to examine the correlation between early graft function and clinical parameters. We experienced 11 cases of kidney transplants from non-heart-beating donors during the period from April 1995 to May 2003. Warm ischemic time was less than 30 min in all cases, and total ischemic time ranged from 8.4 hours to 27.9 hours. Rejection reactions occurred in seven cases, two of which were vascular rejections. Infectious disease complications included CMV in two cases, interstitial pneumonia in one case and fungal infection in one case. One patient died from interstitial pneumonia, and three patients had to be restarted on dialysis due to loss of function of the grafted kidney. The remaining seven patients all made full recoveries. All of the 16 patients who underwent living related kidney transplantations during the same period made full recoveries. Both the donor's gender and the latest creatinine level of the donor influenced the posttransplant dialysis period. The posttransplant dialysis period significantly influenced the creatinine level one month after transplant. These results suggest that patients who undergo kidney transplants from non-heart-beating donors have higher rates of complications than patients who undergo living related kidney transplantation. It is important that, in cases where the donor's creatinine level is high, especially when the donor is male, the kidney is carefully retrieved and transported to the recipent hospital to shorten the ischemic period as much as possible.

Allochronic overlapping malignancies after renal transplantation in a patient with p53 gene mutation: report of a case.

We report a rare case of the development of various tumors over a 16-year period after renal transplantation. A 56-year-old woman underwent renal transplantation using a US kidney. Immunosuppressive treatment consisted of a triple regimen of methylprednisolone, azathioprine, and mizoribine. Left breast cancer was diagnosed 9 years after the renal transplantation, then colon cancers and meningeal epidermal meningioma were diagnosed, 10 years and 12 years post-transplant, respectively. During the investigations for the breast and colon cancers, a p53 gene mutation was detected. A deterioration of renal function was found 16 years after the transplant and graft biopsy confirmed chronic rejection. We suggest that the effects of the immunosuppressive drugs combined with the p53 gene abnormality accelerated tumor development in this patient.

Radiofrequency ablation in the treatment of small hepatocellular carcinomas: comparison of the radiofrequency effect with and without chemoembolization.

OBJECTIVE: The purpose of this study was to determine whether a combination of transcatheter arterial chemoembolization using doxorubicin and radiofrequency ablation can increase tumor destruction compared with radiofrequency alone in the treatment for hepatocellular carcinoma. SUBJECTS AND METHODS. Twenty-one patients with 26 nodules smaller than 3 cm in diameter were treated with radiofrequency ablation. Of these, 10 nodules were treated with a combination of radiofrequency ablation and chemoembolization using doxorubicin. All nodules were evaluated for size of induced coagulation, local recurrence, and complication. RESULTS: The therapeutic areas averaged 27.6 x 22.3 mm using an electrode with a 2-cm tip and 37.2 x 29.1 mm using an electrode with a 3-cm tip. With respect to the results for 14 nodules treated using an electrode with a 3-cm tip with or without chemoembolization, the greatest dimension of the area coagulated by combined therapy was significantly larger (longest axis dimension, 39.9 +/- 4.4 mm; shortest axis dimension, 32.3 +/- 5.2 mm; n = 7 nodules) than areas without chemoembolization (longest axis dimension, 34.6 +/- 2.6 mm; shortest axis dimension, 26.0 +/- 3.3 mm; n = 7 nodules) (longest and shortest axis dimensions, p < 0.05). No recurrence occurred in the nodules smaller than 2 cm in diameter. Among the nodules larger than 2 cm in diameter, one local recurrence was observed in seven nodules treated by combined therapy, while two local recurrences were observed in seven nodules treated by radiofrequency alone. Minor complications developed in three patients, two with persistent high fever and one with biliary stenosis. CONCLUSION: The combination of radiofrequency ablation and transcatheter arterial chemoembolization using doxorubicin markedly increased the extent of induced coagulation compared with radiofrequency alone, despite a small number of patients and the preliminary nature of this study.