[Primary Small Bowel Tumor with Simultaneous Lung Metastases from Rectal Cancer - A Case Report].

A 56-year-old woman was diagnosed with rectal cancer and liver metastases(Stage IV), and underwent low anterior resection and laparoscopic partial hepatectomy. The patient received adjuvant chemotherapy(mFOLFOX6 for 24 weeks), but developed multiple lung metastases 11 months later. Before undergoing a pulmonary resection, the patient presented with acute small bowel obstruction. Abdominal computed tomography showed small bowel stenosis due to a tumor, and we suspected peritoneal metastases from the rectal tumor. We performed partial resection of the small intestine, and histopathological examination revealed a primary small bowel tumor. The patient was discharged to her home without complications, and later underwent pulmonary resections for bilateral lung metastases. We usually suspect that small bowel obstruction is due to peritoneal metastases in patients with advanced colorectal tumors, but must consider the rare possibility of a separate primary small bowel tumor, especially in patients with a solitary lesion. We report a rare primary small bowel tumor after FOLFOX treatment in a patient with Stage IV rectal cancer.

Metachronous solitary mediastinal lymph node metastases of hepatocellular carcinoma treated by video-assisted thoracic surgery twice: Report of a case.

Solitary mediastinal lymph node metastasis of hepatocellular carcinoma (HCC) is rare. We report a case of metachronically solitary mediastinal metastases of HCC treated by video-assisted thoracic surgery (VATS) twice. A 66-year-old man underwent repeated laparoscopic radiofrequency ablation or trans-arterial catheter chemo-embolization against HCC for more than 10 years. The level of alpha fetoprotein protein was elevated, and radiological modalities including FDG-PET revealed solitary mediastinal tumor metachronically. VATS was performed bilaterally twice. The postoperative course was uneventful and there had no recurrence of extra-hepatic metastases and tumor markers are within normal limits at 18 months after second VATS. VATS is a minimally invasive and useful procedure for solitary mediastinal lymph node metastasis of HCC. If primary HCC was controlled and lymph node metastasis was solitary, mediastinum lymphadenectomy using VATS might give good short and long term results.

[A Hematogenous Metastasis from Scirrhous Gastric Cancer to the Uterus].

A 46-year-old woman was referred to our hospital because of nausea. Endoscopy revealed scirrhous gastric cancer, and abdominalcomputed tomography revealed peritonealdissemination. She was diagnosed with Stage IV gastric cancer and treated with S-1 plus CDDP combination chemotherapy. After 4 courses of chemotherapy, the primary tumor and peritoneal dissemination were considered clinically stable, but the uterus grew rapidly. She was diagnosed as having uterine metastasis based on cervicaland endometrialsmear class V cytology. As the chemotherapy was not effective for the uterine lesions, totalhysterectomy and bilateralsal pingo-oophorectomy were performed. Histological findings showed a poorly differentiated cancer with vascular emboli. Uterine metastases are an important consideration in women with scirrhous gastric cancer, and we recommend palliative hysterectomy for chemotherapy-resistant metastases if the primary tumor and other metastases are controlled.

Laparoscopic gastric devascularization without splenectomy is effective for the treatment of gastric varices.

INTRODUCTION: Laparoscopic gastric devascularization of the upper stomach in patients with gastric varices has rarely been reported. Perioperative clinical data were compared with patients who underwent open surgery. PRESENTATION OF CASES: From 2009 to 2012, we performed laparoscopic gastric devascularization without splenectomy for the treatment of gastric varices in eight patients. The patients included four males and four females. Peri-gastric vessels were divided using electrical coagulating devices or other devices according to the diameter of the vessels. Two patients underwent conversion to open surgery due to intraoperative bleeding. DISCUSSION: Intraoperative blood loss in patients who accomplished laparoscopic devascularization was very small (mean 76ml). However, once bleeding occurs, there is a risk of causing massive bleeding. CONCLUSION: With further improvement of laparoscopic devices, laparoscopic gastric devascularization without splenectomy must be an effective and less-invasive surgical procedure in the treatment of gastric varices.

The impact of rituximab in ABO-incompatible pediatric living donor liver transplantation: the experience of a single center.

Previous studies have demonstrated the safety of ABO-incompatible pediatric LDLT using preoperative plasmapheresis and rituximab; however, no reports have described the timing and dosage of rituximab administration for pediatric LDLT. This study aimed to describe a safe and effective dosage and timing of rituximab for patients undergoing pediatric ABO-incompatible LDLT based on the experience of our single center. A total of 192 LDLTs in 187 patients were examined. These cases included 29 ABO-incompatible LDLTs in 28 patients. Rituximab was used beginning in January 2004 in recipients older than two yr of age (first period: 375 mg/m(2) in two cases; second period: 50 mg/m(2) in two cases; and 200 mg/m(2) in eight cases). Two patients who received 375 mg/m(2) rituximab died of Pneumocystis carinii pneumonia and hemophagocytic syndrome. One patient who received 50 mg/m(2) rituximab required retransplantation as a consequence of antibody-mediated complications. All eight patients administered 200 mg/m(2) survived, and the mean CD20(+) lymphocyte count was 0.1% at the time of LDLT. In the preoperative management of patients undergoing pediatric ABO-incompatible LDLT, the administration of 200 mg/m(2) rituximab three wk prior to LDLT was safe and effective.

Preoperative segmental embolization of the proper hepatic artery prior to pylorus-preserving pancreaticoduodenectomy: A case report.

INTRODUCTION: Radical resection of bile duct carcinoma may require resection of hepatic arteries. Preoperative segmental embolization of the hepatic artery for resection of hilar cholangiocarcinoma has been reported. We report a patient with bile duct carcinoma infiltrating the proper hepatic artery. PRESENTATION OF CASE: A 66-year old male with jaundice was diagnosed with mid-distal bile duct carcinoma. A replaced left hepatic artery originated from the left gastric artery. Pylorus-preserving pancreaticoduodenectomy (PPPD) with combined resection of hepatic artery was planned. To promote the development of collateral blood flow after excision of the hepatic artery, preoperative segmental embolization of the proper hepatic artery was performed. The patient underwent PPPD with concurrent resection of the common hepatic, right hepatic, and middle hepatic arteries without arterial reconstruction. He received adjuvant chemotherapy with gemcitabine for six months and is alive three years after surgery without tumor recurrence. DISCUSSION: The growth of collateral vessels after selective embolization of the proper hepatic artery has been used for hilar lesions and bile duct lesions. Resection of the hepatic artery without the need for complex arterial reconstruction, allowing a radical resection, may have contributed to this patient's relatively unremarkable recovery and long-term survival. Retroperitoneal mobilization of the pancreatic head and duodenum must be limited as important collaterals may originate in that area. CONCLUSION: Preoperative segmental embolization of the hepatic artery before PPPD for a patient with a replaced left hepatic artery encouraged the growth of collateral blood supply, allowing radical resection including the vessels and obviated the need for arterial reconstruction.

Living donor liver transplantation from an asymptomatic donor with mild coagulation factor IX deficiency: report of a case.

The use of donors with coagulation FIX deficiency is controversial, and there are no current protocols for peri-transplant management. We herein describe the first reported case of a pediatric LDLT from an asymptomatic donor with mild coagulation FIX deficiency. A 32-yr-old female was evaluated as a donor for her 12-month-old daughter with biliary atresia. The donor's pretransplant coagulation tests revealed asymptomatic mild coagulation FIX deficiency (FIX activity 60.8%). Freeze-dried human blood coagulation FIX concentrate was administered before the dissection of the liver and 12 h afterwards by bolus infusion (40 U/kg) and was continued on POD 1. The bleeding volume at LDLT was 590 mL. On POD 1, 3, 5, and 13, the coagulation FIX activity of the donor was 121.3%, 130.6%, 114.6%, and 50.2%, respectively. The donor's post-transplant course was uneventful, and the recipient is currently doing well at 18 months after LDLT. The FIX activity of the donor and recipient at nine months after LDLT was 39.2% and 58.0%, respectively. LDLT from donors with mild coagulation FIX deficiency could be performed effectively and safely using peri-transplant short-term coagulation FIX replacement and long-term monitoring of the plasma FIX level in the donor.

Recurrent cholangitis by biliary stasis due to non-obstructive afferent loop syndrome after pylorus-preserving pancreatoduodenectomy: report of a case.

We report a 71-year-old man who had undergone pylorus-preserving pancreatoduodenectomy (PPPD) using PPPD-IV reconstruction for cholangiocarcinoma. For 6 years thereafter, he had suffered recurrent cholangitis, and also a right liver abscess (S5/8), which required percutaneous drainage at 9 years after PPPD. At 16 years after PPPD, he had been admitted to the other hospital because of acute purulent cholangitis. Although medical treatment resolved the cholangitis, the patient was referred to our hospital because of dilatation of the intrahepatic biliary duct (B2). Peroral double-balloon enteroscopy revealed that the diameter of the hepaticojejunostomy anastomosis was 12 mm, and cholangiography detected intrahepatic stones. Lithotripsy was performed using a basket catheter. At 1 year after lithotripsy procedure, the patient is doing well. Hepatobiliary scintigraphy at 60 minutes after intravenous injection demonstrated that deposit of the tracer still remained in the upper afferent loop jejunum. Therefore, we considered that the recurrent cholangitis, liver abscess, and intrahepatic lithiasis have been caused by biliary stasis due to nonobstructive afferent loop syndrome. Biliary retention due to nonobstructive afferent loop syndrome may cause recurrent cholangitis or liver abscess after hepaticojejunostomy, and double-balloon enteroscopy and hepatobiliary scintigraphy are useful for the diagnosis of nonobstructive afferent loop syndrome.

Stenosis after use of the double-stapling technique for reconstruction after laparoscopy-assisted total gastrectomy.

BACKGROUND: The double-stapling technique (DST) for esophagojejunostomy using the transorally inserted anvil (OrVil; Covidien Japan, Tokyo, Japan) is one of the reconstruction methods used after laparoscopy-assisted total gastrectomy (LATG). This technique has potential advantages in terms of less invasive surgery without the need to create a complicated intraabdominal anastomosis. METHODS: From 2008 to 2011, 262 patients with gastric cancer underwent total gastrectomy and reconstruction with a Roux-en-Y anastomosis, and 52 patients underwent LATG with DST. A retrospective analysis then was performed comparing the patients who experienced postoperative stenosis after LATG-DST (positive group) and the patients who did not (negative group). A comparative analysis was performed among patients comparing conventional open total gastrectomy and LATG, and multivariate analysis was performed to evaluate risk factors for the development of anastomotic stenosis. RESULTS: A minor leak was found in 1 patient (1.9 %), and 11 patients experienced anastomotic stenosis (21 %) after LATG with DST. Among the patients with anastomotic stenosis, three (3/4, 75 %) anastomoses were performed with the 21-mm end-to-end anastomosis (EEA) stapler, and eight anastomoses were performed (8/47, 17 %) with the 25-mm EEA stapler. The median interval to the diagnosis of anastomotic stenosis was 43 days after surgery. The patients with stenosis needed endoscopic balloon dilation an average of four times, and the rate of perforation after dilation was 13 %. The clinical and operative characteristics did not differ between the two groups. Anastomotic stenosis after open total gastrectomy occurred in two cases (0.98 %). Multivariate analysis showed that the size of the EEA stapler and the use of DST were risk factors for anastomotic stenosis. CONCLUSION: Esophagojejunostomy using DST with OrVil is useful in performing a minimally invasive procedure but carries a high risk of anastomotic stenosis.

Primary hepatic choriocarcinoma in a 49-year-old man: report of a case.

We report a case of hepatic choriocarcinoma in a man diagnosed at autopsy after a rapid downhill clinical course. The patient was a 49-year-old man who presented with acute right-sided abdominal pain. There were no masses palpable on physical examination. Radiographic findings showed large multi-nodular tumors mainly in the right lobe of the liver. Fludeoxyglucose-positron emission tomography scan showed uptake only in the liver, and no uptake in the testes. We initially planned to perform a liver resection for the presumed diagnosis of intra-hepatic cholangiocarcinoma. However, the tumors grew rapidly and ruptured. Multiple lung metastases rapidly developed resulting in respiratory failure, preventing liver resection or even biopsy. He died 60 d after initial presentation with no pathological diagnosis. Postmortem studies included histopathological and immunohistological examinations which diagnosed a primary choriocarcinoma of the liver. Primary hepatic choriocarcinoma is very rare but should be considered in the differential diagnosis of a liver tumor in a middle aged man. Establishing this diagnosis may enable treatment of the choriocarcinoma. Liver biopsy and evaluation of serum human chorionic gonadotropin are recommended in these patients.

Participation of surgical residents does not adversely affect the outcome of inguinal hernia repair in an integrated teaching program.

OBJECTIVE: The Lichtenstein inguinal hernia repair is commonly performed and suitable for teaching basic surgical skills. The objective of this study is to evaluate the feasibility of this procedure for surgical training, particularly in regard to patient outcomes. DESIGN: Retrospective case review after introduction of an integrated teaching program. SETTING: University teaching hospital. PARTICIPANTS: The Lichtenstein inguinal hernia repair is the standard procedure for adult primary unilateral inguinal hernia since 2003 at Jichi Medical University. We introduced an integrated teaching system of lectures, skill training. and videos to teach the skills for Lichtenstein inguinal hernia repair to residents and junior faculty in 2003. Cases were retrospectively divided into 4 groups based on the experience of the operating surgeon; junior residents (PGY 1-2, group A), senior residents (PGY 3-5, group B), junior faculty (PGY 6-10, group C), and senior faculty (PGY 11 or more, group D). Background, perioperative factors, and outcomes were evaluated among the groups. RESULTS: A total of 246 elective inguinal hernia repairs (group A: 136, group B: 49, group C: 42, group D: 19) were performed. There was a significant difference in the frequency of concomitant diseases (p = 0.012) and anticoagulant therapy (p = 0.031). Average operating time was 80.7 ± 24.9, 72.6 ± 20.8, 63.5 ± 22.0, and 54.7 ± 27.9 (min ± SD) in groups A, B, C, and D, respectively, with a significant difference between groups A and D (p < 0.001). No significant differences were observed in estimated blood loss (p = 0.216) or morbidity (p = 0.294). CONCLUSIONS: The Lichtenstein inguinal hernia repair can be safely performed by residents and junior faculty with the appropriate supervision of senior faculty without any disadvantage to patients. This integrated teaching program for Lichtenstein inguinal hernia repair is effective and feasible for training residents and junior faculty.

Pediatric living donor liver transplantation using liver allograft with hemangioma.

BACKGROUND: Although liver transplantation using liver allograft with hemangiomas has been previously reported, little is known about the fate of hemangiomas in the transplanted liver. We herein describe a case of pediatric living donor liver transplantation (LDLT) using living donor liver allograft with a hemangioma which is considered to the first reported case performing in vivo hemangioma resection. CASE REPORT: A 27-year-old female was evaluated as a donor for her 2-year-old son with cholestatic cirrhosis due to biliary atresia. Preoperative ultrasonography and computed tomography revealed a 20-mm hemangioma located at lateral side of segment 3. During LDLT, an in vivo partial hepatic resection of the hemangioma of segment 3 was performed without the Pringle maneuver using intraoperative ultrasonography to keep the main portal triad of segment 3 before the donor liver resection, and the left lateral segment graft without the hemangioma, which underwent an intraoperative pathologic diagnosis, was transplanted into the recipient. The donor's postoperative course was uneventful and the recipient course was not observed subsequent liver necrosis, bleeding or bile leakage from the resection site. CONCLUSIONS: Liver allografts with hemangiomas can be accepted as potential liver allografts, and such hemangiomas should undergo be performed in vivo resection during LDLT irrespective of tumor size.

Pediatric living donor liver transplantation for biliary atresia with hepatopulmonary syndrome: the gift of a second wind.

PURPOSE: Hepatopulmonary syndrome (HPS) is a progressive, deteriorating complication of end-stage liver disease (ESLD) that occurs in 13-47% of liver transplant candidates. Although LT is the only therapeutic option for HPS, it has a high morbidity and mortality, especially in patients with severe hypoxemia before transplantation, but the course of HPS after living donor liver transplantation (LDLT), especially for biliary atresia (BA) patients is not well established. PATIENTS AND METHODS: The present study evaluated 122 patients who received an LDLT for BA and of these, 3 patients had HPS at the time of LDLT in a single-center series. RESULTS: Two patients of the HPS patients them had biliary and/or vascular complications, but they recovered uneventfully with interventional treatment. None of the patients required supplemental oxygen and had no residual cardiopulmonary abnormalities at a follow-up of more than 24 months. CONCLUSION: Although a series of three patients is too small for definitive conclusion and further investigations must be conducted, pediatric LDLT can be a favorable therapeutic option for HPS.

Bowel perforation after pediatric living donor liver transplantation.

PURPOSE: Bowel perforation after liver transplantation (LT) is a rare, but highly lethal complication with a poor prognosis. Here, we report the outcome of cases of bowel perforation after pediatric LT in our department. PATIENTS AND METHODS: The study subjects were 148 patients who underwent pediatric living donor liver transplantation. The 114 with biliary atresia (BA) were divided into two groups: those with associated bowel perforation (Group A) and those without (Group B). RESULTS: Four patients in all (2.5%) suffered bowel perforation. Their original disease was BA and emergency surgery was performed in all cases, with a mortality rate of 50.0%. Comparison of Groups A and B revealed significant differences in the patient age, body weight, duration of surgery, cold ischemic time, and blood loss volume. The survival rates in Groups A and B were 50.0 and 99.1%, respectively (p < 0.01). Duration of surgery was an independent risk factor (p = 0.05). CONCLUSION: Bowel perforation after LT is a potentially fatal complication. LT is a procedure that requires care and precision, and the possibility of bowel perforation should always be borne in mind during post-operative management, when the duration of surgery has been long.

Depot-specific expression of lipolytic genes in human adipose tissues--association among CES1 expression, triglyceride lipase activity and adiposity.

AIM: Adipocyte lipolysis is mediated by a family of triglyceride (TG) lipases consisting of hormone-sensitive lipase (LIPE), adipose triglyceride lipase (PNPLA2) and carboxylesterase 1 (CES1); however, little is known about the relationship between the expression of each gene in different depots and TG lipase activity or obesity. METHOD: We measured both mRNA expression levels of the lipolytic enzymes (LIPE, PNPLA2 and CES1) and TG lipase activities of biopsy samples obtained from subcutaneous, omental and mesenteric adipose tissues of 34 patients who underwent abdominal surgery. The results were correlated with clinical parameters: adiposity measures, parameters for insulin resistance and plasma lipid levels. RESULTS: PNPLA2 mRNA levels were slightly higher in omental fat than subcutaneous fat. Cytosolic TG lipase activities were positively correlated with the mRNA levels of CES1 in subcutaneous fat and mesenteric fat, while they were correlated with those of PNPLA2 in omental fat. The mRNA levels of LIPE were negatively correlated with various measures of adiposity in subcutaneous fat. The mRNA levels of CES1 were positively correlated with various measures of adiposity, particularly those estimated by CT in the three depots; they were also positively correlated with plasma LDL-cholesterol levels in omental fat. In contrast, the mRNA levels of PNPLA2 were not significantly associated with adiposity. CONCLUSIONS: The positive correlations of the expression of CES1 with cytosolic TG lipase activities as well as with adiposity suggest that CES1 is involved in lipolysis, thereby contributing to the development of obesity-associated phenotypes. On the other hand, the expression of LIPE is negatively correlated with adiposity. These distinct regulatory patterns of lipolytic genes may underlie the complex phenotypes associated with human obesity.

Double-balloon enteroscopy for bilioenteric anastomotic stricture after pediatric living donor liver transplantation.

Bilioenteric anastomotic stricture after liver transplantation is still frequent and early detection and treatment is important. We established the management using double-balloon enteroscopy (DBE) and evaluated the intractability for bilioenteric anastomotic stricture after pediatric living donor liver transplantation (LDLT). We underwent DBE at Jichi Medical University from May 2003 to July 2009 for 25 patients who developed bilioenteric anastomotic stricture after pediatric LDLT. The patients were divided into two types according to the degree of dilatation of the anastomotic sites before and after interventional radiology (IVR) using DBE. Type I is an anastomotic site macroscopically dilated to five times or more, and Type II is an anastomotic site dilated to less than five times. The rate of DBE reaching the bilioenteric anastomotic sites was 68.0% (17/25), and the success rate of IVR was 88.2% (15/17). There were three cases of Type I and 12 cases of Type II. Type II had a significantly longer cold ischemic time and higher recurrence rate than Type I (P = 0.005 and P = 0.006). In conclusion, DBE is a less invasive and safe treatment method that is capable of reaching the bilioenteric anastomotic site after pediatric LDLT and enables IVR to be performed on strictures, and its treatment outcomes are improving. Type II and long cold ischemic time are risk factors for intractable bilioenteric anastomotic stricture.

Carcinoid tumor of the gallbladder: report of two cases.

We report two cases of carcinoid tumor of the gallbladder. Case 1 was a 59-year-old woman who presented with epigastric pain. Abdominal ultrasonography and computed tomography (CT) revealed a 16 mm polypoid lesion in the neck of the gallbladder. Tumor markers were within normal limits. Open cholecystectomy was performed with a preoperative diagnosis of early cancer of the gallbladder. Case 2 was a 45-year-old man. A polyp in the gallbladder was incidentally detected on annual checkup. Ultrasound and CT showed an 18 mm protruding lesion in the neck of the gallbladder. Laparoscopic cholecystectomy was performed and the tumor diagnosed as a carcinoid tumor based on the findings of funicular and tubular cells in the lamina propria mucosa, homogeneous nuclei, basophilic cytoplasm, and positive staining with chromogranin A and synaptophysin. The postoperative course of both patients was uneventful, with no recurrence at 44 and 41 months after surgery. In this literature review of 39 cases, classical carcinoid of the gallbladder has a favorable postoperative outcome. Of cases reviewed, 60% are located in the neck of the gallbladder and 50% have a polypoid shape.

Adenocarcinoma of the minor duodenal papilla treated with pancreas-sparing segmental duodenectomy: case report and review of the literature.

Carcinoma of the minor duodenal papilla is extremely rare. We present the case of a 69-year-old man diagnosed with a tumor of the second portion of the duodenum by upper gastrointestinal endoscopy, which revealed a 1.5-cm elevated tumor with slight ulceration at the minor duodenal papilla. Biopsy revealed adenocarcinoma, and a computed tomography scan showed an enhanced tumor in the duodenum, with no abnormality in the pancreatic head. A pancreas-sparing segmental duodenectomy was performed, and the duodenum reconstructed with an end-to-end anastomosis. Microscopically, the tumor was a well-differentiated adenocarcinoma, with no infiltration at the cut end of the accessory pancreatic duct. The postoperative course was uneventful and the patient discharged on postoperative day 11. We reviewed previously reported cases of carcinoma of the minor duodenal papilla. Early and exact preoperative diagnosis of duodenal neoplasms makes it possible to select a less invasive treatment, which also maintains curability.

Right anterior segmental hepatic duct emptying directly into the cystic duct in a living donor.

A 35-year-old mother was scheduled to be the living donor for liver transplantation to her second son, who suffered from biliary atresia complicated with biliary cirrhosis at the age of 2 years. The operative plan was to recover the left lateral segment of the mother's liver for living donor transplantation. With the use of cholangiography at the time of surgery, we found the right anterior segmental duct (RASD) emptying directly into the cystic duct, and the catheter passed into the RASD. After repairing the incision in the cystic duct, transplantation was successfully performed. Her postoperative course was uneventful. Biliary anatomical variations were frequently encountered, however, this variation has very rarely been reported. If the RASD was divided, the repair would be very difficult because the duct will not dilate sufficiently in an otherwise healthy donor. Meticulous preoperative evaluation of the living donor's biliary anatomy, especially using magnetic resonance cholangiography and careful intraoperative techniques, is important to prevent bile duct injury and avoid the risk to the healthy donor.

[A case of acinar cell carcinoma of pancreas with liver metastases treated effectively by S-1].

A 65-year-old man underwent a total gastrectomy and distal pancreatectomy for acinar cell carcinoma of the pancreas. Multiple metastatic liver lesions were found one year postoperatively. He was treated with S-1 chemotherapy over 34 months, and the tumors significantly reduced in size without severe side effects. Four years after surgery, the liver metastases increased in size, associated with pain especially in the right upper quadrant. We then performed right hepatectomy. Peritoneal dissemination and multiple lung metastases were found 8 months after liver resection. Acinar cell carcinoma of the pancreas is a rare and highly malignant tumor, and there are few reports regarding treatment with chemotherapy. Herein, we report a case with multiple liver metastases which were controlled by systemic chemotherapy using S-1.