An adenocarcinoma in an inverted Meckel's diverticulum with intussusception.

BACKGROUND: Adenocarcinoma in an inverted Meckel's diverticulum with intussusception has not been reported to date. We discuss the clinical issues concerning this rare condition and review the relevant literature. CASE PRESENTATION: A 71-year-old Japanese female was referred to our hospital for further investigation of severe anemia. Computed tomography revealed a tumorous lesion in the terminal ileum. Capsule endoscopy did not provide detailed images. Exploratory laparoscopy revealed intussusception in the terminal ileum. An intraluminal tumor 70 cm proximal to the ileocecal valve was observed to be the lead point. Partial resection including the tumor was performed. Macroscopically, a polypoid tumor at the tip of an inverted diverticulum-like structure was observed. The tumor was histologically composed of adenocarcinoma accompanied by gastric and pyloric gland metaplasia in the background mucosa, which was confirmed by immunohistochemical staining. Based on these characteristics, this tumor is considered to have developed from the ectopic gastric mucosa in a Meckel's diverticulum. CONCLUSIONS: When we encounter patients with unfamiliar lesions in the small bowel, we need to differentiate Meckel's diverticulum related disease. Meckel's diverticulum can invert into the lumen of the small bowel and cause an intussusception, and has potential of malignant transformation.

Efficacy of Prophylactic Negative-Pressure Wound Therapy with Delayed Primary Closure for Contaminated Abdominal Wounds.

Background: Prophylactic negative-pressure wound therapy (NPWT) to prevent surgical site infection (SSI) may be effective for severely contaminated wounds. We investigated the safety and efficacy of NPWT with delayed primary closure (DPC) for preventing SSI. Methods: For patients with contaminated and dirty/infected surgical wounds after an emergency laparotomy, the abdominal fascia was closed with antibacterial absorbent threads and the skin was left open. Negative pressure (-80 mmHg) was applied through the polyurethane foam, which was replaced on postoperative days 3 and 7. DPC was performed when sufficient granulation was observed. The duration and adverse events of NPWT, the development of SSI, and the postoperative hospital stay were retrospectively reviewed. Results: We analyzed the cases of patients with contaminated (n = 15) and dirty/infected wounds (n = 7). The median duration of NPWT was 7 days (range 5-11 days). NPWT was discontinued in one (4.5%) patient due to wound traction pain. SSI developed in seven patients (31.8%), with incisional SSI in one (4.5%) and organ/space SSI in six (27.3%). The median postoperative hospital stay was 17 days (range 7-91 days). There was no significant relationship between postoperative hospital stay and wound classification (P=0.17) or type of SSI (P=0.07). Conclusion: Prophylactic NPWT with DPC was feasible and may be particularly suitable for severely contaminated wounds, with a low incidence of incisional SSI.

Feasibility and educational value of fluorescence cholangiography in laparoscopic cholecystectomy.

INTRODUCTION: Near-infrared fluorescence cholangiography during a laparoscopic cholecystectomy has become widely accepted as a useful auxiliary tool to visualize the extrahepatic biliary structures. We investigated the feasibility and educational value of a method with longer interval between the administration of indocyanine green and the imaging of these structures. METHODS: Approximately 18 hours before their surgery, patients (n = 51) were intravenously administered 0.25 mg/kg of indocyanine green. Each laparoscopic cholecystectomy was performed under fluorescence imaging in combination with white-light imaging. Operative outcomes including visualization of the extrahepatic biliary structures and operative time were compared between the patients on whom board-certified surgeons operated (feasibility phase; n = 18) and the patients on whom a surgery resident operated (educational phase; n = 33). RESULTS: There were no adverse events related to the longer interval method. The visualization rates of extrahepatic biliary structures were comparable between the two phases. Both the mean time to divide the cystic duct and the mean time to remove the gallbladder in the educational phase were significantly longer than those in the feasibility phase (68.2 vs 24.4 minutes and 30.2 vs 15.8 minutes, P < .001 each). There was no significant difference in other operative outcomes. The operative time learning curve did not decrease with a resident's experience. CONCLUSIONS: Fluorescence cholangiography with the longer interval method was feasible and could identify the extrahepatic biliary structures irrespective of the surgeon's experience; however, it did not decrease the operative time with experience.

Vitamin D Deficiency-induced Osteomalacia in a Patient with Anorexia Nervosa.

A 48-year-old woman with a 9-year-history of anorexia nervosa (AN) was admitted complaining of generalized bone pain. Blood tests showed hypocalcemia and hyperphosphatasemia, and a radiological survey revealed multiple rib fractures, suggesting complication with osteomalacia. Two years earlier, she had undergone subtotal colectomy for colon cancer. Her serum 25-hydroxy vitamin D concentration was below the detectable level. In addition to a poor nutritional intake and insufficient sun exposure, malabsorption of fat-soluble substances in the intestine and phosphate loss from the kidneys might have contributed to the development of her osteomalacia.

Non-insulin-dependent Diabetes Mellitus Induced by Immune Checkpoint Inhibitor Therapy in an Insulinoma-associated Antigen-2 Autoantibody-positive Patient with Advanced Gastric Cancer.

A 70-year-old man with insulinoma-associated antigen-2 autoantibodies developed diabetes mellitus (DM) without ketoacidosis after starting nivolumab to treat advanced gastric cancer. He subsequently exhibited preserved insulin-secretion capacity for over one year. Immune checkpoint inhibitors (ICIs) infrequently cause type 1 DM associated with the rapid loss of insulin secretion and ketoacidosis as an immune-related adverse event. ICIs may also cause non-insulin-dependent DM by inducing insulin resistance if there is islet autoantibody-related latent beta-cell dysfunction. The present case highlights the importance of testing blood glucose levels regularly to diagnose DM in patients treated with ICIs, even if they do not have diabetic ketoacidosis.

Unusual lymph node metastasis from cancer of the thoracic esophagus.

A 76-year-old male received concurrent chemoradiotherapy, at a dose of 60 Gy with low-dose 5-fluorouracil, for cT1bN0M0 squamous cell carcinoma of the mid-thoracic esophagus. Because his primary tumor relapsed with mediastinal and right supraclavicular node metastasis 4 months after completion of chemoradiotherapy, right transthoracic esophagectomy with mediastinal and right cervical lymphadenectomy was performed. However, metastatic tumors developed deep beneath the anterior border of the trapezius muscle 2 months after esophagectomy. En bloc dissection of the adipose tissue including the tumor and the transverse cervical artery was performed, followed by adjuvant radiotherapy of 50.4 Gy to the area of dissection. The patient died of pneumonia 11 months after metastasectomy, with locally recurrent disease. We have had three cases of this unusual lymph nodes metastasis from cancer of the thoracic esophagus to date and here present the characteristic imaging findings and the possible mechanism of this unusual lymph node metastasis.

Cardiac tamponade communicating with a posterior mediastinal chylocele after esophagectomy.

A 75-year-old male received neoadjuvant chemotherapy for locally advanced squamous cell carcinoma of the mid-thoracic esophagus, followed by right transthoracic esophagectomy with extended mediastinal lymphadenectomy. Cardiac tamponade developed on postoperative Days 1 and 13, for which emergency ultrasound-guided drainage was required. Pericardial drainage fluid became chylous after administration of polymeric formula. A computed tomography scan demonstrated the presence of a retrocardiac fluid collection, encompassed by the left pulmonary vein and left atrium, descending aorta and vertebral column. Based on these findings, the diagnosis of chylopericardial tamponade communicating with a posterior mediastinal chylocele was made. The ligation of the thoracic duct was successfully performed via the left-sided thoracoscopic approach on postoperative Day 20 and the clinical course after the second operation was uneventful. The possible mechanisms of this exceptionally rare complication after esophagectomy were discussed.

Short-and long-term outcomes of surgery for diffuse peritonitis in patients 80 years of age and older.

PURPOSE: We evaluated the impact of advanced age on the morbidity, mortality, and long-term outcome after emergency surgery for diffuse peritonitis. METHODS: We retrospectively evaluated the mortality and morbidity rates in 36 patients who were 80 years of age or older and who had undergone emergency surgery for diffuse peritonitis, and calculated 5-year survival by the Kaplan-Meier method. Factors compromising prognosis were identified by univariate and multivariate analyses. RESULTS: The median patient age was 84 years (range, 80-97 years); 16 patients were men and 20 were women. Preoperative concomitant disease was present in 81% of patients; cardiac disease was most common. Sites of visceral perforation were in the upper gastrointestinal tract in five patients, colon or rectum in 30, and gallbladder in 1. The postoperative morbidity rate was 72%, the surgical mortality rate was 11%, and the in-hospital mortality rate was 28%. The median hospital stay was 56 days. The median survival was 41 months, with a 5-year survival rate of 23%. A multivariate analysis identified number of failing organs as the only independent adverse prognostic factor (P < 0.001; relative risk 5.51, 95% confidence interval 1.97-15.4). CONCLUSIONS: Elderly patients with diffuse peritonitis had an unsatisfactory rate of short-term morbidity and mortality compared with those undergoing elective surgery. Postoperative organ failure was most likely to compromise survival.

Characteristics of biliary reconstruction, using a T-tube, as compared to those with other methods, in left-lobe adult living-donor liver transplantation.

BACKGROUND/PURPOSE: Postoperative biliary tract complications remain one of the most serious problems facing patients who undergo living-donor liver transplantation. The aim of this study was to analyze the clinical implications of three different methods of biliary reconstruction in left-lobe adult living-donor liver transplantation. METHODS: We retrospectively compared three groups of patients: those who had Roux-en-Y hepaticojejunostomy (HJ; n = 11) biliary reconstruction, those who had duct-to-duct hepaticohepaticostomy (HH) with external stent (n = 11), and those who had HH with a T-tube (n = 6). Median follow-up for each group was 31, 30, and 10 months, respectively. RESULTS: Bile leaks were observed in 45.5% of the patients in both the HJ group and the HH with external stent group. Biliary anastomotic strictures occurred in 9% of the Roux-en-Y HJ patients and in 27.2% of those who had HH with external stent. No biliary complications were observed in the HH with a T-tube group (P = 0.049). CONCLUSIONS: Biliary reconstruction using HH with a T-tube may decrease the incidence of biliary complications. Despite the relatively short follow-up period, these encouraging preliminary results may warrant further studies of this biliary reconstruction technique in left-lobe adult living-donor liver transplantation.

FK506 may reduce early liver injury following living related liver transplantation.

BACKGROUND/AIMS: We investigated the influence of FK506 which has been used frequently after transplant surgery as an immunosuppressant, on liver injury after partial hepatectomy by comparing laboratory data from donors and recipients after liver transplantation. METHODOLOGY: Seventeen donors and respective recipients who underwent living related donor liver transplantation were included in the present study. Serum levels of transaminases and cytokines were measured and compared preoperatively and in the early period after the operation. RESULTS: Serum level of asparaginic acid aminotransferase in the postoperative day 1 was significantly higher in the donor group. Serum levels of alanine aminotransferase in the early period after the operation were significantly higher in the donor group. Serum levels of interferon y and soluble Fas ligand in the early period after the operation were significantly higher in the donor group. Steroid doses administered were significantly higher in the recipient group. CONCLUSIONS: FK506 administration and steroid administration in larger doses were thought to reduce serum transaminase levels of the recipient group. These findings might suggest that cell-mediated immunity weigh heavier than the operation time of ischemia-reperfusion injury as a cause of liver injury after partial hepatectomy.

Management of major portosystemic shunting in small-for-size adult living-related donor liver transplantation with a left-sided graft liver.

PURPOSE: We investigated the mechanisms of small-for-size graft syndrome by time-lag ligation, a novel approach to treating major portosystemic shunts in small-for-size adult living-related donor liver transplantation (LRDLT) using left-sided graft liver. METHODS: Five patients with end-stage liver failure and major splenorenal shunting underwent LRDLT using left lobe grafts. The average graft volume to recipient body weight (GV/RBW) ratio was 0.68 +/- 0.14. Two patients underwent time-lag ligation of their splenorenal (SR) shunts on postoperative days (PODs) 8 and 14, respectively. The shunts of the other three patients were untreated. RESULTS: The portal pressures in the first patient who underwent time-lag ligation rose above 300 mmH(2)O and remained there for 2 weeks. Thus, we ligated the SR shunt in the second patient on POD 14, resulting in an increase from 177 mmH(2)O to 258 mmH(2)O, but it decreased again thereafter. In the other three patients, the SR shunt was not ligated because portal blood flow volumes remained sufficient. Total bilirubin levels in the first time-lag ligation patient rose to 16 mg/dl, paralleling the rise in portal pressures. Although they increased after ligation in the second patient, they did not exceed 10 mg/dl. CONCLUSIONS: We recommend time-lag ligation if portal venous blood flow decreases in the early post-transplant period, but not until at least 2 weeks after transplantation. If the portal venous blood flow does not decrease, early postoperative ligation is unnecessary. If there are no major portosystemic shunts, making a portosystemic shunt might decompress excessive portal hypertension. With donor safety priority in LRDLT, novel approaches must be developed to enable the use of smaller donor grafts. We describe a potential means of using left lobe grafts in adult LRDLT.

Diagnostic peritoneal lavage for diagnosing blunt hollow visceral injury: the accuracy of two different criteria and their combination.

PURPOSE: To test the usefulness of diagnostic peritoneal lavage (DPL) for identifying blunt hollow visceral injury with two different sets of criteria or a combination of the two. METHODS: Fifty victims with physical examinations and/or computed tomography findings equivocal for blunt hollow visceral injury underwent DPL. Whether or not to perform surgery was determined based on Otomo's DPL criteria [lavage white blood cell counts (L-WBC) over lavage red blood cell counts (L-RBC) divided by 150 (L-WBC > or = L-RBC/150) in the presence of hemoperitoneum, or L-WBC over 500/mm(3) (L-WBC > or = 500) in the absence of hemoperitoneum]. The cell count ratio, a comparison of L-WBC, L-RBC, peripheral WBC (P-WBC), and peripheral RBC (P-RBC) [(L-WBC/L-RBC)/(P-WBC/P-RBC) > or = 1] were all calculated retrospectively. RESULTS: There were one and two false-positive cases based on Otomo's criteria and the cell count ratio, respectively, with corresponding accuracies of 97.8% and 95.7%, respectively. There were no false-positive or -negative cases according to the combined use of Otomo's criteria and cell count ratio, yielding an accuracy of 100%. CONCLUSION: Although each criterion alone is very accurate in predicting the presence of blunt hollow visceral injury, the combined use of the two would further improve the accuracy of the diagnosis and thereby reduce the number of unnecessary celiotomies.

Preoperative human-telomerase reverse transcriptase mRNA in peripheral blood and tumor recurrence in living-related liver transplantation for hepatocellular carcinoma.

BACKGROUND/AIMS: In this study we evaluated the potential role of preoperative h-TERT mRNA expression in peripheral blood as a tool for predicting prognosis and tumor recurrence after living-related liver donor transplantation (LRLDT). METHODOLOGY: The study included patients with unresectable HCC who underwent LRLDT from July 1999 to May 2003. RESULTS: There was no significant difference between the survival curves of those patients who met the Milan criteria and those who did not. However, there was a statistically significant difference (p=0.032) between the survival curves of those patients with positive preoperative h-TERT mRNA expression, and those who either had an initially negative preoperative h-TERT mRNA or who converted from positive to negative after neoadjuvant immunochemotherapy. CONCLUSIONS: In conclusion, the presence or absence of h-TERT mRNA in the peripheral blood may be a useful criterion in evaluating HCC patients for transplantation, as well as a valuable method of assessing anti-tumor therapy and tumor relapse.

Successful surgical treatment for hepatocellular carcinoma and concomitant risky esophageal varices.

BACKGROUND/AIMS: In our frequent encounters with liver cirrhotic patients with hepatocellular carcinoma (HCC) and concomitant risky esophageal varices, we have found that some of them required endoscopic injection sclerotherapy (EIS) and/or surgical treatment for esophageal variceal bleeding due to increased portal venous pressure after aggressive hepatectomy. In this study, we investigated the short-term effect of aggressive hepatectomy accompanied with left gastric venous caval shunt (Inokuchi's shunt) for esophageal varices and postoperative liver function. METHODOLOGY: Four cirrhotic patients with HCC and concomitant risky esophageal varices underwent hepatectomy with Inokuchi's shunt from 1999 to 2001. The mean age was 58.0 +/- 15.3 years old and all patients were classified in Child grade A or B. We investigated hematochemical data and endoscopic findings before and after surgery. RESULTS: One of the patients experienced disappearance of esophageal varices at discharge. In the others, postoperative endoscopy showed disappearance of CRS and reduced sizes of varices. In one patient, hepatic encephalopathy appeared transiently with bleeding from a duodenal ulcer at one month after surgery. However, the patient improved by conservative treatment. Three of the patients have survived well without recurrence of HCC and esophageal variceal bleeding; the remaining patient died from a recurrence of HCC. CONCLUSIONS: Inokuchi's shunt may be sufficiently effective to treat risky esophageal varices associated with resectable HCC and may be safe even if it is undertaken along with a major hepatectomy.

Augmentation of heme oxygenase-1 expression in the graft immediately after implantation in adult living-donor liver transplantation.

Heme oxygenase (HO)-1 is a cytoprotective protein and has recently been identified as a graft survival gene. However, there are little data currently available regarding the expression of HO-1 in human living-related liver transplantation. This is the first report that HO-1 expression is increased in small-for-size liver allografts. We performed biopsies of the graft liver and donor liver left in six patients at four time points during the procedure and studied HO-1 expression by reverse-transcriptase polymerase chain reaction and immunohistochemistry. HO-1 mRNA was expressed at a low level in steady-state liver tissue but was strongly expressed after perfusion of the graft liver. HO-1 expression increased in nonparenchymal cells in the human graft liver. The number of HO-1 positive cells increased threefold by the end of liver transplantation. This study suggests that ischemia-reperfusion injury and excessive shear stress secondary to portal hypertension might augment HO-1 expression in the graft liver.

Carbon monoxide hemoglobin and bilirubin metabolism in adult living-related liver transplantation.

BACKGROUND/AIMS: Hemeoxygenase-1 produces carbon monoxide as a byproduct of hemoglobin metabolism. The present study examines the relationship between carbon monoxide production and hyperbilirubinemia following adult living-related liver transplantation with special attention to the contribution of shear stress in retarding regeneration. METHODOLOGY: Case records from 16 patients who underwent adult living-related liver transplantation from March 1999 to May 2001 were reviewed. Patients were divided into group A (graft weight: recipient body weight ratio > or = 1) and group B (graft weight: recipient body weight ratio < 1). Clinical characteristics and outcome in the two groups were compared. RESULTS: Total serum bilirubin concentration and the direct: total serum bilirubin concentration were higher in group B than group A (p < 0.01). Further, the carbon monoxide-hemoglobin concentration correlated with the total serum bilirubin concentration (r = 0.81, p < 0.0001) and also was higher in group B than group A (p < 0.05). The arterial: ketone body ratio rose similarly during the first week in both groups. CONCLUSIONS: Persistent hyperbilirubinemia in small-for-size grafts and concomitant carbon monoxide-hemoglobinemia reflect both parenchymal and Kupffer cell dysfunction. The role of shear stress in the portal system and its relationship to portal hypertension are discussed.

The protective role of Kupffer cells in the ischemia-reperfused rat liver.

Kupffer cells constitute a major source of the heme-degrading enzyme, heme oxygenase (HO). This study examined the roles of Kupffer cells in the modulation of accelerated heme catabolism in ischemia-reperfused rat livers. Livers from rats treated with or without liposome-encapsulated dichloromethylene diphosphonate, a Kupffer cell-depleting reagent, underwent a 20-min ligation of the portal vein followed by reperfusion, The time course of the biliary output of bilirubin, the terminal heme-degrading product, and the expression of HO-1 mRNA and protein were monitored. HO-1 mRNA levels were elevated 3 to 12 h after ischemia/reperfusion in both control and Kupffer cell-depleted rats. Immunohistochemical analyses of control livers revealed that Kupffer cells expressed high levels of HO-1 while its expression in hepatocytes was low. In Kupffer cell-depleted livers, however, periportal hepatocytes displayed marked HO-1 expression. Under these conditions the two groups exhibited distinct profiles of biliary bilirubin excretion. In the controls, total bilirubin excretion increased 8-fold and peaked at 10 h after ischemia/reperfusion. In contrast, the Kupffer cell-depleting treatment resulted in a significant acceleration of the initial rise in bilirubin production, which peaked at 4 h. However, the total amount of bilirubin excreted within the initial 10 h after reperfusion was reduced by 50% as compared with that of the controls. In Kupffer cell-depleted rats, the levels of GOT and GPT as well as serum endotoxin concentrations were elevated after ischemia/reperfusion. These results suggest that Kupffer cells serve as an ischemia/reperfusion sensor that upregulates heme degradation and bilirubin excretion, and that Kupffer cells protect hepatocytes from gut-derived stressers--including endotoxin--following ischemia/reperfusion.