Clinical outcome of internal stent for biliary anastomosis in liver transplantation.

BACKGROUND: This study analyzed the incidence and management of biliary complications after liver transplantation (LT) with or without internal stent. METHODS: The medical record of all patients who underwent LT and were hospitalized from December 2009 to March 2013 were reviewed. Patients were grouped into 2 groups (internal stent group vs no stent group). RESULTS: There were 29 deceased-donor liver transplantations (58%) and 21 living-donor liver transplantations (42%). There were 2 perioperative mortalities, and those 2 patients were excluded from this study. The overall biliary complication rate was 6.45% in the internal stent group and 17.65% in the no stent group. The rate of anastomotic stricture was 3.23% (n = 1) in the stent group and 11.76% (n = 2) in the no stent group. The rate of bile leak was 3.23% (n = 1) in the stent group and 0% in the no stent group. The rate of biliary obstruction was 0% in the stent group and 5.88% (n = 1) in the no stent group. CONCLUSIONS: The overall rate of biliary complications in the internal stent group was lower than in the no stent group, and most of the biliary complications could be treated successfully with endoscopic or radiologic intervention.

Does procurement technique affect posttransplant graft function in deceased donor liver transplantation?

INTRODUCTION: Various techniques have been described deceased donor liver transplantation (DDLT) procurement. One is a technique whereby almost total dissection is done in the porta hepatis and perihepatic detachment is carried out before cross-clamping the donor aorta. In another approach, after the donor aorta is cross-clamped, rapid and minimal en bloc dissection is performed with minimal manipulation. We evaluated early posttransplant graft function among liver procurement techniques. METHOD: Between January 2008 and August 2012, we performed 45 consecutive adult DDLTs. One patient was excluded from this analysis due to early death from sepsis after transplantation. The 44 included patients were divided into two cohorts according to the procurement technique: A warm dissection (n = 23; 52%) and a cold dissection group (n = 21; 48%). We compared early posttransplant graft function using the aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin (T-bil), and prothrombin time (PT) values of the two groups from the first to seventh postoperative day. RESULT: The AST values in the warm group were significantly greater than those in the cold group on postoperative days 3 and 5. In addition, the ALT values in the warm group were greater than those in the cold group on postoperative days 4, 5, and 6. Moreover, the T-bil values in the warm group were greater than those in the cold group on postoperative days 2, 3, 4, 5, 6, and 7. However, there were no differences in PT values. CONCLUSION: During liver procurement for DDLT, rapid en bloc procurement with minimal manipulation after clamping the donor aorta achieved better early graft function posttransplantation.

Pre-emptive therapy for the cytomegalovirus infection after liver transplantation in endemic areas and its optimal diagnostic method.

BACKGROUND: The incidence of positive cytomegalovirus (CMV) IgG tests among Asian populations is high. Both universal prophylaxis and pre-emptive therapy (PT) have been recommended for the moderate-risk group (D+/R+), whose incidence of CMV infection has been reported variously, and for whom the optimal diagnostic method has not been firmly established. Herein, we sought to analyze our experience with CMV infections using PT and to discuss the optimal diagnostic method. METHODS: We retrospectively, analyzed 32 consecutive liver transplant recipients between December 2009 and April 2012 for clinicopathologic data including mortality and rejection rates, comparing 2 diagnostic tools for CMV: pp65 antigen assay and real-time reverse-transcriptase polymerase chain reaction (RT-PCR). RESULTS: Twenty-one patients (65.6%) were positive for the CMV antigen assay, and 13 (40.6%) had positive RT-PCR results. There were no cases of CMV disease during the follow-up and no difference in rejection (P = .529) or mortality (P = .471) rates with regard to PCR positivity. The mean diagnosis time was 26.5 days postoperative. Among the patients who exhibited negative RT-PCR results, 7 (41.18%) were positive on the pp65 antigen assay. CONCLUSION: CMV infection rates were higher when compared to same-risk population from Western countries. As a diagnostic tool for CMV infection, screening with the pp65 antigen assay and confirmation with real-time RT-PCR seemed to provide an optimal diagnostic tool.

Right posterior portal vein stenosis developed after living donor liver transplantation using a modified right lobe graft with a type 2 portal vein: a case report.

Portal vein complications after liver transplantation (LT) can lead to graft liver failure. In this living donor liver transplantation case a stenosis developed in the right posterior branch of the portal vein of the graft liver from a living donor with type 2 portal vein variation. A 61-year-old woman diagnosed with hepatocellular carcinoma due to hepatitis B received a liver graft revealing a single lumen divided by a septum. The portal vein was anastomosed to the recipient portal vein without venoplasty. Postoperative Doppler sonogram revealed poor flow in the right posterior portal vein with compensatory arterial hyperperfusion. The postoperative computed tomography (CT) scan revealed narrowing of the proximal part of the right posterior portal vein with periportal tracking. Without intervention, the liver enzyme and bilirubin levels decreased to normal and the follow-up CT scan showed decreased periportal tracking. The patient was discharged without major complications. We believe that the posterior portal vein stenosis resulted from the direct anastomosis of the portal vein without a further venoplasty. Although there was no major complication due to the posterior portal vein stenosis in our patient, we suggest a venoplasty to prevent portal vein stenosis when using right lobe grafts with a type 2 portal vein, even if a single lumen is present and there is a margin for a direct anastomosis.

Concurrent inferior vena cava and hepatic vein stenoses after orthotopic liver transplantation: a case report.

Outflow obstruction or stenosis of a hepatic graft is a rare but serious complication after liver transplantation, with a reported incidence of 1% to 6%. It can cause signs of portal hypertension, renal dysfunction, or lower-extremity edema depending on the level of obstruction, which may lead to patient mortality. Most reported cases show a stenosis at either the inferior vena cava (IVC) or one of the hepatic veins. Herein we have reported our experience of concurrent suprahepatic IVC and hepatic vein stenoses after orthotopic liver transplantation with related imaging findings and a successful treatment outcome. Due to the complexity of stenoses, two self-expandable metallic stents were placed simultaneously using different venous accesses.

Surgical outcomes and prognostic factors for ampulla of Vater cancer.

BACKGROUND AND AIMS: The prognosis for patients with ampulla of Vater cancer is better than other periampullary cancers. The aim of the present study is to determine the clinicopathologic factors predictive of survival and recurrence in patients with ampulla of Vater cancer. MATERIAL AND METHODS: From 1991 to 2008, we identified and reviewed 78 patients with ampulla of Vater cancer retrospectively. Clinicopathologic factors possibly influencing survival and recurrence were statistically analyzed. RESULTS: Pancreaticoduodenectomy was performed in 68 patients and 2 patients underwent transduodenal ampullectomy. Hospital mortality was 2.6%. The 5-year survival rates following resection were 59.9%. Univariate analysis for overall survival revealed that total bilirubin greater than 5 mg/dl, ulcerative tumors, differentiation, and pancreatic invasion were significant prognostic factors. Recurrence occurred in 31 patients. Univariate analysis for disease-free survival revealed that total bilirubin greater than 5mg/dl, preoperative biliary drainage, tumor differentiation, and stage were statistically significant. Multivariate analysis revealed that tumor differentiation was an independent prognostic factor for recurrence. The presence of lymph node metastasis did not affect overall survival significantly in this study. However, two or more metastatic lymph nodes significantly affect disease-free survival. CONCLUSIONS: Pancreaticoduodenectomy is a safe surgical procedure with acceptable long-term survival for ampulla of Vater cancer. Pancreaticoduodenectomy with lymph node dissection might control lymph node spread and enhance survival outcome.

The functional significance of microRNA-145 in prostate cancer.

BACKGROUND: MicroRNAs (miRNAs) are small noncoding RNAs that have important roles in numerous cellular processes. Recent studies have shown aberrant expression of miRNAs in prostate cancer tissues and cell lines. On the basis of miRNA microarray data, we found that miR-145 is significantly downregulated in prostate cancer. METHODS AND RESULTS: We investigated the expression and functional significance of miR-145 in prostate cancer. The expression of miR-145 was low in all the prostate cell lines tested (PC3, LNCaP and DU145) compared with the normal cell line, PWR-1E, and in cancerous regions of human prostate tissue when compared with the matched adjacent normal. Overexpression of miR-145 in PC3-transfected cells resulted in increased apoptosis and an increase in cells in the G2/M phase, as detected by flow cytometry. Investigation of the mechanisms of inactivation of miR-145 through epigenetic pathways revealed significant DNA methylation of the miR-145 promoter region in prostate cancer cell lines. Microarray analyses of miR-145-overexpressing PC3 cells showed upregulation of the pro-apoptotic gene TNFSF10, which was confirmed by real-time PCR and western analysis. CONCLUSION: One of the genes significantly upregulated by miR-145 overexpression is the proapoptotic gene TNFSF10. Therefore, modulation of miR-145 may be an important therapeutic approach for the management of prostate cancer.

Successful vaginal delivery following laparoscopic abdominal wall reconstruction in an adult survivor of an omphalocele without prior surgical repair: report of a case.

We report the case of a successful vaginal delivery following laparoscopic abdominal wall reconstruction in an adult survivor of an omphalocele without prior surgical repair. Untreated omphaloceles are rare in adulthood. A 30-year-old female patient presented with a large anterior abdominal wall defect due to an untreated omphalocele, who expressed a desire to have a baby in the near future. A laparoscopic herniorrhaphy was performed with a double-layered expanded polytetrafluoroethylene (ePTFE, Gore-Tex) mesh. The patient delivered a full-term healthy baby vaginally 2 years after surgical repair of the omphalocele.

Systemic immune response after open versus laparoscopic cholecystectomy in acute cholecystitis: a prospective randomized study.

OBJECTIVE: Laparoscopic surgery is thought to reduce the postoperative immunologic effects of surgical trauma. The aim of this study is to evaluate the influence of surgical trauma on systemic inflammation and the immune response in acute cholecystitis. MATERIAL AND METHODS: Thirty-three patients with acute calculous cholecystitis were assigned to laparoscopic cholecystectomy (LC, n=18) or open cholecystectomy (OC, n=15). Blood samples were obtained preoperatively and on postoperative day 1 (24 h after surgery) and day 3 (72 h after surgery), and blood concentration of C-reactive protein (CRP), leukocyte subpopulations, as well as levels of tumor necrosis factor-alpha (TNF-alpha) ex vivo secretion by peripheral blood mononuclear cells (PBMCs) were measured in both groups. RESULTS: Hospitalization was significantly shorter in the LC group than in the OC group (LC group: 3.7+/-1.2 days versus OC group: 6.3+/-2.7 days, p=0.010). There was no postoperative morbidity in the LC group, but two patients in the OC group had postoperative complications. Postoperative TNF-alpha ex vivo secretion by PBMCs and PBMC counts in the OC group were significantly lower than those in the LC group (p=0.002). The CRP level declined by postoperative day 3, but was significantly less in the OC group than in the LC group (p<0.001). Postoperative monocyte counts significantly decreased in the OC group compared with those in the LC group (p=0.001). CONCLUSIONS: A laparoscopic approach appears to cause less surgical trauma and immunosuppression than open surgery in patients with acute cholecystitis.

T-lymphocyte subsets in patients with AJCC stage III gastric cancer during postoperative adjuvant chemotherapy. American Joint Committee on Cancer.

BACKGROUND AND AIMS: Advanced neoplastic diseases alter the immune response in cancer patients. The aim of this study was to evaluate the changes of T-lymphocyte subsets during postoperative adjuvant chemotherapy, and the relationship between T-lymphocyte subsets and tumor recurrence in AJCC stage III gastric cancers. MATERIAL AND METHODS: Analysis of T-lymphocyte subsets was performed in 39 patients with stage III gastric adenocarcinoma who had undergone a curative gastric resection and postoperative chemotherapy. CirculatingT-lymphocyte subsets were measured on venous blood by using flow cytometry and monoclonal antibodies on preoperative day 1, and postoperative months 1, 3, and 6. RESULTS: The 5-year disease-free survival rates of patients with stage 3a and 3b gastric cancer were 57.1% and 33.3%, respectively (p = 0.06). Values of CD3+ and CD4+ T-cells, and CD4+/CD8+ ratios were consistently lower in the recurrence group throughout the observation period. CD4+ T-cell counts were significantly lower in the recurrence group on preoperative day 1, and postoperative months 1 and 6. However, most values of the T-lymphocyte subsets showed no statistically significant difference when comparing the stage 3a and 3b disease patient groups. CONCLUSIONS: The results of this study suggest that immunosuppression associated with CD3+ and CD4+ T-cell depression is a risk factor for postoperative recurrence in patients with stage III gastric cancer.

The Seoul experience of splenic artery aneurysms.

BACKGROUND AND AIMS: Aneurysms of the splenic artery (SAA) are the most common type of aneurysms found in the splanchnic arterial bed (1) and are second in frequency only to aortic and iliac artery aneurysms among intra-abdominal aneurysms (2). Historically rupture occurs in 6-9.2% of asymptomatic cases and in pregnant women rupture occurs in 95% of afflicted women further emphasizing the importance of early diagnosis (3-5). Possible treatments are surgical resection or trans-catheteral arterial embolization. MATERIAL AND METHODS: The relationship of SAA to pregnancy, pancreatitis and the outcome after surgical resection or arterial embolization was studied. Fifteen patients were diagnosed with SAA between January, 1992 and December 1999. The patients were classified by their clinical characteristics, etiology, size, and location of the aneurysm, relationship to pregnancy in women, clinical outcome of ruptured aneurysms and treatment. RESULTS: Fifteen patients, male to female ratio of 1.1:1 (eight men, seven women), with splenic artery aneurysm were treated. Patients were mostly in their sixty's and the mean age was 49.07. Chronic pancreatitis and pseudocysts were found in four cases (26.7%). Acute pancreatitis, portal hypertension, splenomegaly, and bronchitis were comorbidities found each in one case (6.7%). Eight cases (53.3%) were without associated disease CONCLUSIONS: SAA has historically shown predominance in women, but in this study, men showed predominance and no relation to pregnancy could be found. In cases were the aneurysms ruptured and treatment was initiated, one of four patients died. One patient refused treatment and subsequently died. As most of the aneurysms measure over 2 cm at the time of detection, operative resection was recommended in all cases. In the high-risk patients, arterial embolization using coiling can be effective early in treatment, but arterial embolization in SAA secondary to pancreatitis was shown only to be palliative and needed to be complimented with surgical intervention. Arterial embolization is the method of choice in high-risk patients.

Insect symbiosis: derivation of yeast-like endosymbionts within an entomopathogenic filamentous lineage.

Yeast-like endosymbionts (YLSs) of insects often are restricted to specific hosts and are essential to the host's survival. For example, in planthoppers (Homoptera: Delphacidae), endosymbionts function in sterol utilization and nitrogen recycling for the hosts. Our study, designed to investigate evolutionary changes in the YLS lineage involved in the planthopper association, strongly suggests an origin of the YLSs from within the filamentous ascomycetes (Euascomycetes), not the true yeasts (Saccharomycetes), as their morphology might indicate. During divergence of the planthopper YLSs, dramatic changes would have occurred in the insect-fungus interaction and the fungal morphology that have previously been undescribed in filamentous ascomycetes. Phylogenetic trees were based on individual and combined data sets of 2.6 kb of the nuclear small- and large-subunit ribosomal RNA genes for YLSs from three rice planthoppers (Laodelphax striatellus, Nilaparvata lugens, and Sogatella furcifera) compared with 56 other fungi. Parsimony analysis placed the planthopper YLSs within Cordyceps (Euascomycetes: Hypocreales: Clavicipitaceae), a genus of filamentous insects and a few fungal pathogenic ascomycetes. Another YLS species restricted to the aphid Hamiltonaphis styraci (Homoptera: Aphididae) was a sister taxon to the planthopper YLSS: Filamentous insect pathogens (Metarhizium and Beauveria) specific to the same species of insect hosts as the YLSs also formed lineages within the Clavicipitaceae, but these were distinct from the clade comprising YLS species. Trees constrained to include the YLSs in families of the Hypocreales other than the Clavicipitaceae were rejected by the Kishino-Hasegawa test. In addition, the results of this study support a hypothesis of two independent origins of insect-associated YLSs from among filamentous ascomycetes: the planthopper YLSs in the Clavicipitaceae and the YLSs associated with anobiid beetles (Symbiotaphrina species). Several lineages of true yeasts (Saccharomycetes) also formed endosymbiotic associations with beetles, but they were not closely related to either group derived from the filamentous ascomycetes.

Host Specialization in the Charcoal Rot Fungus, Macrophomina phaseolina.

ABSTRACT To investigate host specialization in Macrophomina phaseolina, the fungus was isolated from soybean, corn, sorghum, and cotton root tissue and soil from fields cropped continuously to these species for 15 years in St. Joseph, LA. Chlorate phenotype of each isolate was determined after growing on a minimal medium containing 120 mM potassium chlorate. Consistent differences in chlorate sensitivity were detected among isolates from different hosts and from soil versus root. To further explore genetic differentiation among fungal isolates from each host, these isolates were examined by restriction fragment length polymorphism and random amplified polymorphic DNA (RAPD) analysis. No variations were observed among isolates in restriction patterns of DNA fragments amplified by polymerase chain reaction covering the internal transcribed spacer region, 5.8S rRNA and part of 25S rRNA, suggesting that M. phaseolina constitutes a single species. Ten random primers were used to amplify the total DNA of 45 isolates, and banding patterns resulting from RAPD analysis were compared with the neighbor-joining method. Isolates from a given host were genetically similar to each other but distinctly different from those from other hosts. Chlorate-sensitive isolates were distinct from chlorate-resistant isolates within a given host. In greenhouse tests, soybean, sorghum, corn, and cotton were grown separately in soil infested with individual isolates of M. phaseolina that were chosen based on their host of origin and chlorate phenotype. Root colonization and plant weight were measured after harvesting. More colonization of corn roots occurred when corn was grown in soil containing corn isolates compared with isolates from other hosts. However, there was no host specialization in isolates from soybean, sorghum, or cotton. More root colonization in soybean occurred with chlorate-sensitive than with chlorate-resistant isolates.

A Group I intron in the nuclear small subunit rRNA gene of Cryptendoxyla hypophloia, an ascomycetous fungus: evidence for a new major class of Group I introns.

The ascomycetous fungus Cryptendoxyla hypophloia contains an insertion of 433 base pairs in the genes encoding nuclear small subunit ribosomal RNA. Secondary structure analyses of the insert reveal characteristics indicative of a Group I intron, including elements P, Q, R, and S; however, the sequences of these conserved regions deviate significantly from recognized consensus sequences for Group I introns. Principal-components analysis, based on 79 nucleotide positions from the conserved core sequences of 93 Group I introns, identified 17 introns similar to that of C. hypophloia. This grouping, which includes inserts from phylogenetically diverse organisms, cannot readily be classified in any previously recognized major group of Group I introns. We propose the creation of a new group, IE, to accommodate these sequences, and discuss the evolutionary relationships between group IE and other major groups of Group I introns.

Macroamylasemia in a patient with acute appendicitis: a case report.

Macroamylasemia is a condition of persistent, elevated serum amylase activity with no apparent clinical symptoms of a pancreatic disorder. In Korea, however, no such case has been reported to date. We report a case of a 17-year-old female diagnosed with macroamylasemia and acute appendicitis. One day earlier, she developed epigastric and right lower quadrant abdominal pain. She was characterized by high level of serum amylase, but normal lipase. Amylase isoenzyme analysis demonstrated increased fraction of salivary type and follow-up amylase level was persistently increased. Immunofixation disclosed the macroamylase binding with an immunoglobulin, consisting of IgA and kappa chain. The patient was treated by appendectomy, and the abdominal pain subsided.

Phylogenetic analysis of the ballistosporous anamorphic genera Udeniomyces and Bullera, and related basidiomycetous yeasts, based on 18S rDNA sequence.

The small subunit nuclear ribosomal DNA (18S rDNA) sequence was determined for twelve species of basidiomycetous anamorphic yeasts, i.e. three species of Udeniomyces, seven species of Bullera, Cryptococcus albidus and Phaffia rhodozyma. For phylogentic analysis, these sequences were aligned with published sequences for 36 other fungal species. Molecular phylogenetic analysis of maximum likelihood and parsimony showed that the 44 species of basidiomycetes analysed were divided into three major lineages. The ballistosporous yeast genera Udeniomyces and Bullera were clearly separated. On the phylogenetic tree, Udeniomyces megalosporus, U. puniceus and U. piricola showed a very close relationship with one another, and composed a lineage with Mrakia frigida, P. rhodozyma and Cystofilobasidium capitatum at high bootstrap confidence level. On the other hand, eight species of Bullera made lineages with selected species of Tremella (Tremellaceae), Filobasidium and Filobasidiella (Filobasidiaceae), Cryptococcus albidus and Trichosporon cutaneum. The molecular phylogeny deduced from the 18S rDNA sequence showed a possibility of heterogeneity among the species of Bullera at the generic level.

Phylogeny among the basidiomycetous yeasts inferred from small subunit ribosomal DNA sequence.

The sequence of the small subunit nuclear ribosomal DNA (18S rDNA) was determined for seven selected species of the teliospore-forming yeasts and Filobasidiaceae in the basidiomycetous yeasts. A phylogenetic tree, including published reference sequences, was inferred from 1623 sites which could be unambiguously aligned. The molecular phylogeny, using a chytridiomycete as an outgroup, divided the eight basidiomycetous yeasts into two groups which correlated well with both septal ultrastructure (simple pore or dolipore) and cellular xylose (present or absent). The first group included the teliospore-forming yeasts Rhodosporidium toruloides and Leucosporidium scottii, and Erythrobasidium hasegawianum, which is currently a member of the Filobasidiaceae. The second group was formed by the filobasidiaceous yeasts, comprising a Cystofilobasidium capitatum/Leucosporidium lari-marini/Mrakia frigida branch, and a Filobasidium floriforme/Filobasidiella neoformans branch. Our molecular data support the principal chemotaxonomic and ultrastructural evidence, which indicates a very close affinity between C. capitatum and L. lari-marini.

Phylogenetic analysis of basidiomycetous yeasts by means of 18S ribosomal RNA sequences: relationship of Erythrobasidium hasegawianum and other basidiomycetous yeast taxa.

The basidiomycetous yeast genus Erythrobasidium Hamamoto, Sugiyama & Komagata, based on the type species E. hasegawianum Hamamoto et al., is characterized by filobasidiaceous basidia and the Q-10 (H2) system as its major ubiquinone. It is tentatively placed in the Filobasidiaceae. The molecular characterization is based on 18S ribosomal RNA sequence comparisons among the basidiomycetous yeasts, and the ultrastructural characterization on the cell wall and hyphal septal pores in E. hasegawianum clearly indicate a close relationship with the teliospore-forming yeasts Rhodosporidium toruloides and Leucosporidium scottii. Our molecular phylogeny with statistical analysis suggests that the existing taxonomic system of basidiomycetous yeasts, based primarily on the morphology of basidia including the teliospores (probasidia), should be revised.

Sympodiomycopsis: a new yeast-like anamorph genus with basidiomycetous nature from orchid nectar.

A description is provided for a new anamorph genus Sympodiomycopsis (Hyphomycetes), which is neither ballistosporogenous nor sterigmatosporogenous. The genus is typified by S. paphiopedili sp. nov. and accommodates one species which was isolated from nectar of Paphiopedilum primurinum in Japan. Phenotypically, the genus shows some similarity to Sympodiomyces because of the presence of a yeast morph with sympodial conidiogenous cell proliferation, but it is distinguished from that genus morphologically by a yeast morph with the enteroblastic-annellidic conidiogenesis and the conspicuous development of a hyphal morph with holoblastic-sympodial conidiogenous cells, and chemotaxonomically by the ubiquinone system Q-10 and 10% difference in the guanine plus cytosine (G + C) content of the nuclear DNA. Phylogenetically, the type of cell wall and septal pore ultrastructure, and the primary biochemical and chemotaxonomic characters of S. paphiopedili indicate a basidiomycetous affinity.

A case of primary T-cell lymphoma of the duodenum.

Primary malignant lymphoma located in the duodenum is a rarity. A case of primary lymphoma of the duodenum in a 27-year-old man, in which the 2 discrete masses of duodenal bulb and the second portion with pancreatic head invasion was found, is reported here. Immunohistochemical evaluation of the present case showed that lymphoma cells expressed the T-cell markers MT1 and UCHL1. Treatment consisted of pancreaticoduodenectomy followed by antineoplastic chemotherapy.