Successful perioperative management of a patient with idiopathic thrombocytopenic purpura undergoing emergent appendectomy: Report of a case.

INTRODUCTION: Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disease characterized by a low platelet count and normal bone marrow. Patients with ITP undergoing surgery are thought to have increased risk for postoperative complications because of their thrombocytopenia. PRESENTATION OF CASE: we report the case of a 66-year-old woman with ITP who required an emergency operation for acute appendicitis associated with disseminated intravascular coagulation. Preoperative therapy consisted of platelet transfusions only, and intraoperative hemostasis was achieved. Postoperatively, high-dose intravenous immunoglobulin (IVIg) therapy led to an increased, stable, and adequate platelet count and good hemostasis. DISCUSSION: The outcome of this case suggests that IVIg therapy is not always required for preoperative management of patients with. CONCLUSION: IVIg therapy may be useful for postoperative management after emergency surgery.

Laparoscopy-assisted distal gastrectomy for early gastric cancer with versus without prophylactic drainage.

PURPOSE: Little has been reported on routine prophylactic abdominal drainage after gastrectomy, especially after laparoscopy-assisted distal gastrectomy (LADG). We conducted this retrospective study on patients undergoing LADG to evaluate the benefit of routine drainage in LADG procedures. METHODS: The subjects were 21 patients who underwent surgery for early gastric cancer (EGC) between January 2004 and March 2008. They comprised 10 who underwent LADG with drainage before January 2006 and 11 who underwent LADG without drainage after February 2006. We compared patient and tumor characteristics, operative results, and postoperative outcomes between the groups. RESULTS: The no-drain group of patients were able to eat their first meal significantly sooner than the drain group patients (P < 0.01); however, the time to start ambulating, passing flatus, and drinking was similar in the two groups. There were no significant differences between the groups in the postoperative complication rate or the postoperative hospital stay. The drain did not seem to add benefit, and no complications due to the lack of drain placement were noted in the no-drain group. CONCLUSION: Routine prophylactic abdominal drainage after LADG for EGC may not be necessary.

Laparoscopic cholecystectomy with and without abdominal prophylactic drainage.

AIM: As techniques in laparoscopic cholecystectomy (LC) have improved, the role of routine prophylactic abdominal drainage may be limited. A retrospective review was carried out of patients undergoing elective LC to evaluate the benefit of routine drainage in simple uncomplicated procedures. METHODS: This study of 295 patients with cholecystolithiasis or gallbladder polyp included 145 patients who underwent LC with drainage and 150 patients who underwent LC without drainage between 2003 and 2007. Allocation to drain or not to drain was non-randomized and based on surgeon preference according to intraoperative findings. Patient characteristics, operative results, and postoperative outcomes were compared between the two groups with univariate analysis. RESULTS: Time to first flatus and length of postoperative hospital stay in the LC without drainage group were shorter than in the LC with drainage group. There was no significant difference between the two groups with respect to postoperative complication rate. No complications were noted due to the lack of drain placement. CONCLUSION: The use of drain after simple elective uncomplicated LC could safely be limited to appropriate patients as judged by the operating surgeon.

Immunohistochemical Examination of a Resected Advanced Hilar Cholangiocarcinoma Arising in a 29-Year-Old Male without Primary Sclerosing Cholangitis.

A 29-year-old man with advanced hilar cholangiocarcinoma was successfully treated with an extended right lobectomy. The carbohydrate antigen 19-9 (CA19-9) level was elevated to 939 IU/l, and the pathological findings revealed moderately differentiated tubular adenocarcinoma which involved almost the entire thickness of the hepatic duct and the adjacent liver tissue (T3) and which was associated with lymph node metastasis (N1). It was a stage IIB (T3N1M0) tubular adenocarcinoma according to UICC pathological staging. Immunohistochemical examination revealed that Ki-67, cyclin D1, and MMP-7 were positive, and 14-3-3sigma and p27 were negative. The pathological and immunohistochemical findings indicated high malignant potential indicating poor prognosis. We administrated the postoperative adjunct gemcitabine combined with S-1 chemotherapy. The patient is alive without recurrence and doing well two years after surgery. We also review other reports of cholangiocarcinoma patients aged less than 30 years.

Prolonged antibiotic prophylaxis longer than 24 hours does not decrease surgical site infection after elective gastric and colorectal surgery.

BACKGROUND/AIMS: Prophylactic administration of antibiotics can decrease postoperative morbidity, shorten hospitalization, and reduce overall costs. In Western countries, it is stressed that antimicrobial prophylaxis was discontinued within 24 hrs after surgery in currently published guidelines. However, it is unclear how long we need to continue perioperative prophylaxis for gastrointestinal surgery. In this manuscript, we analyzed surgical site infection (SSI) in gastric and colorectal surgery according to the duration of antibiotics prophylaxis and discuss the duration of an antibiotic prophylaxis, and its relation to SSI. METHODOLOGY: We studied 228 patients who underwent digestive surgery including 94 with gastric cancer, 85 with colon cancer and 49 with rectal cancer. RESULTS: Overall SSI was seen in 28 cases (12.2%), 8 cases (8.5%) in gastrectomy, 10 cases (11.8%) in colectomy and 10 cases (20.4%) in rectal surgery. In SSI positive cases, operative time was longer (p=0.01), blood loss was more (p=0.01) and duration was longer (p=0.01) than in SSI negative cases. The duration of prophylactic antibiotics was significantly longer in 28 patients with SSI than in the 200 non-SSI patients (3.5 +/- 1.8 vs. 2.3 +/- 1.7 days; p<0.05). CONCLUSIONS: From our findings, SSI rate did not decrease with longer duration of antimicrobial prophylaxis. We concluded that we must recognize that the cause of postoperative wound infection is multimodal, and should not rely on antibiotics to prevent postoperative SSI but that surgeons should reduce the risk for postoperative SSI.

A case of retroperitoneal mucinous cystadenoma treated successfully by laparoscopic excision.

A case of retroperitoneal mucinous cystadenoma treated laparoscopically is reported. A 26-year-old woman, who complained of abdominal fullness, was referred to us after a large intra-abdominal mass was discovered at her local hospital. Ultrasound and computed tomography showed a fluid-filled mass, 9 cm in diameter, in the left retroperitoneal space. Laparoscopic surgery was performed. We found a smooth and thin-walled cystic tumor that displaced the descending colon to the right and arose from the retroperitoneum, loosely adhering to the psoas muscle. We successfully extirpated the tumor laparoscopically. The surgical specimen consisted of a multilocular, red to yellowish-gray, cystic mass with a smooth, glistening external surface, and inner lining. The mass was filled with thin, yellowish fluid. The histologic diagnosis was benign mucinous cystadenoma. The postoperative course was uneventful, and the patient remains free of recurrence 15 months after surgery. Retroperitoneal mucinous cystadenoma is a rare entity, and the treatment of choice is surgical excision. Laparoscopic extirpation should be considered for the treatment of selected retroperitoneal cystic lesions.

Large mucinous cystadenoma of the pancreas during pregnancy: report of a case.

A 33-year-old woman, gravida 2, para 1, was diagnosed to have a benign mucinous cystic neoplasm of the pancreas 5 months before delivery. The tumor measured 12 cm in diameter at the time of diagnosis. The antenatal course was uneventful, and a vaginal delivery produced a normal infant. By 2 months after delivery, the tumor reached 18 cm. At surgery, a huge cyst was found to originate from the pancreas, and a distal pancreatectomy with splenectomy was performed. The cystic mass was multilocular 18 x 17 x 12 cm, 2450 g, and red to yellowish-gray. The histologic diagnosis was benign mucinous cystadenoma. The postoperative course was uneventful, and the patient remains free of recurrence at 7 months after surgery. To our knowledge, this is only the fifth reported case of pancreatic mucinous cystadenoma in association with pregnancy. This is the first reported case of a successful resection of such a tumor after delivery.

Hepatocellular carcinoma producing a granulocyte colony-stimulating factor: report of a resected case with a literature review.

A complete resection of a hepatocellular carcinoma (HCC) producing the granulocyte colony-stimulating factor (G-CSF) was performed and is reported here. The patient had a few general symptoms and complications, such as the paraneoplastic syndrome. He had marked granulocytosis, and his serum levels of G-CSF and interleukin-6 were elevated. The pathological findings of the resected specimen revealed poorly differentiated HCC with sarcomatous change and showed, immunohistochemically, staining of G-CSF. Only a few cases of G-CSF-producing HCC have been reported, and they resulted in rapid tumour growth and poor prognosis. The case presented here may be the first complete resection ever performed, but the patient's prognosis was similar to that observed in typical cases.

Successful conservative treatment of a bicycle-handlebar hernia: report of a case.

Handlebar hernia is a rare type of blunt traumatic abdominal wall hernia (TAWH). It involves a disruption of the abdominal wall muscles, with bowel loop herniation through the defect in the abdominal wall. We report a case of bicycle-handlebar hernia in a 9-year-old boy who had all layers of his abdominal wall disrupted after falling from his bicycle. He was brought to our hospital with lower abdominal pain and bulging. A physical examination revealed left lower quadrant bulging in a standing posture, and a palpable fascial defect, 3 cm in diameter. Computed tomography showed a disruption of the abdominal rectal muscle layer, but his skin and intra-abdominal organs were completely intact. The patient was treated conservatively with abdominal wall compression using a cotton cloth corset. Within 3 weeks, his abdominal wall hernia had healed without the need for any surgical intervention.

Self-expandable metallic stents as palliative treatment for malignant colorectal obstruction.

BACKGROUND: In recent years, stent placement for malignant colorectal obstruction has become an accepted alternative to surgery. The purpose of this study was to evaluate the usefulness of self-expandable metallic stents (SEMS) as palliative management for patients with unresectable malignant colorectal obstruction. METHODS: Twelve patients with unresectable malignant colorectal obstruction were treated with SEMS as palliative therapy. The sites of obstruction were located in the rectum (n = 9), the descending colon (n = 1), and the transverse colon (n = 2). All procedures were performed with combined endoscopic and fluoroscopic guidance. We analyzed the technical and clinical success rates of stent placement and the complications associated with the procedure. RESULTS: The stents were successfully implanted and bowel obstruction was relieved in all cases; the technical and clinical success rates were 100%. Two complications occurred, including stent migration. There was no case requiring reintervention. All patients died of initial disease or another coexisting disease between 9 and 534 days (mean 133 +/- 148 days) after stent placement. None of the patients with stent in position at death had clinical or radiologic signs of bowel obstruction. CONCLUSIONS: SEMS placement in patients with malignant colorectal obstruction is technically feasible and safe, making it useful as a palliative treatment.

Hyperinsulinemia in patients with colorectal cancer.

BACKGROUND/AIMS: It has been reported that non-insulin dependent diabetes mellitus (NIDDM) is one of the risk factors for colorectal cancer. Usually, in the pre-NIDDM state, hyperinsulinemia is seen for 5 to 8 years. Insulin is the growth factor of epithelial and cancer cells of colon and rectum. In this study, we evaluate glucose tolerance in the patients with colorectal cancer who were never diagnosed with DM. METHODOLOGY: We studied 82 patients with colon cancer who were never diagnosed with DM. 75-g glucose tolerance test (75g GTT) was performed and we measured serum glucose (BS) and insulin (IRI) levels, and we defined them as normal glucose tolerance (NGT), impaired GT (IGT), and DM. We also defined hyperinsulinemia as highest IRI levels over 100mU/mL at 75g GTT. RESULTS: Serum glucose and insulin levels were higher in the patients with colorectal cancer than in healthy controls. In 82 colorectal cancer patients, 39 were IGT and 5 were DM. All DM patients also had hyperinsulinemia. Only 14 patients (17%) had NGT and normal IRI levels. CONCLUSIONS: Our findings suggest that hyperinsulinemia is occasionally seen in patients with colorectal cancer. Hyperinsulinemia may be one of the causes of colorectal cancer and we have to control hyperinsulinemia to prevent recurrence of colorectal cancer even after curative resection.

The effect of the herbal medicines dai-kenchu-to and keishi-bukuryo-gan on bowel movement after colorectal surgery.

BACKGROUND/AIMS: To evaluate the safety and efficacy of the herbal medicines Dai-ken-chu-to and Keish-bukuryo-gan in the patients undergoing colorectal resection. METHODOLOGY: Sixty-six patients undergoing colorectal resection were studied. Patients in the Study group began on 7.5g of Dai-ken-chu-to and 6.0g of Keish-bukuryo-gan on the first postoperative day. Control group did not take herbal medicine at all. All of the patients were monitored for vomiting, abdominal distention, length of ileus, tolerance of regular diet, duration of intravenous fluid administration, length of hospitalization, and complications. RESULTS: The time to flatus was 63.1 +/- 22.8 hours and 95.4 +/- 33.0 hours in the Study and Control group, respectively (p<0.05). And the time to tolerance of regular diet was 2.53 +/- 1.93 days and 6.25 +/- 1.50 days in the Study and Control group, respectively (p<0.05). In addition, length of postoperative hospitalization in the patients within the Study group was significantly shorter than those within the Control group (15.7 +/- 4.8 days vs. 20.8 +/- 4.8 days, p<0.05). The incidence of complications including nausea, vomiting, anastomotic leak and wound infection occurred equally in both groups. CONCLUSIONS: Administration of Dai-ken-chu-to and Keish-bukuryo-gan is safe, with no evidence of increased morbidity, and is also highly effective in improving postoperative bowel motility and in reducing hospital stay.

Change in alpha glutathione s-transferase levels during liver resection.

BACKGROUND/AIMS: Alpha-glutathione s-transferase (GST) is a 50,000-kDa cytosol protein of the hepatocytes. It comprises 5% of the soluble protein of hepatocytes and is readily released in response to injury. Its half-life time is 60 minutes (AST: 47 hrs, ALT: 22 hrs). The aim of this study is to clarify the usefulness of GST measurement during liver resection. We obtained data from 26 patients undergoing liver resection and compared GST levels with AST and ALT levels. METHODOLOGY: Patients included 15 hepatocellular carcinoma, 5 cholangiocellular carcinoma and 6 metastatic cancers (4: colon, 2: stomach). We performed lobectomy for 11, segmentectomy for 5 and partial resection for 10 patients. From these patients, blood samples were collected before surgery, beginning of resection, end of resection, 15, 30, 60 min after resection, end of surgery, 1, 3, 6, 12, 24 hr after operation and 2, 3, 4, 5, 6, 7, 10, 14 postoperative days (POD). GST (Biotrin, Ireland) levels in the serum samples were determined by an ELISA. We also measured AST, ALT levels from the same set of samples. RESULTS: At the end of resection, GST showed highest level and quickly decreased at 1 hr after operation. On the other hand, AST and ALT showed peak levels at 12 hr after operation. CONCLUSIONS: Our findings suggest that perioperative GST measurement may be a sensitive and useful marker to evaluate liver function after liver resection.

Preoperative hyaluronic acid measurement to assess the hepatic functional reserve.

BACKGROUND/AIMS: With liver surgery, preoperative assessment of the hepatic functional reserve is important for estimating the extent of hepatectomy. Hyaluronic acid (HA) is specifically cleared and metabolized by endothelial cells in the liver. Its half-life time is 2-5 min and HA might be a sensitive liver function marker. We obtained data from 44 patients with liver tumor undergoing liver resection. METHODOLOGY: We studied 44 liver resected patients. Blood samples were obtained before surgery and HA levels and other liver function markers [type IV collagen (IV), procollagen-III-peptide (PIIIP), lecithin-cholesterol acyltransferase (LCAT), cholinesterase (ChE), albumin (Alb), platelets (Plt), prothrombin time (PT%)] levels in the samples were measured. We also performed indocyanine green retention test and calculate R15% (ICG). RESULTS: HA showed strong positive correlation with ICG, IV and PIIIP, negative correlation with LCAT, ChE, Alb, Plt and PT%. ICG was not correlated with ChE, Plt and PT%. The HA levels and ICG of the patients who had more than 2 segments of the liver resected were below 100 ng/mL and 20%, respectively. In the patients with obstructive jaundice HA levels of the 3 patients with obstructive jaundice who underwent bisegmentectomy were below 100 ng/mL. CONCLUSIONS: Our findings suggest that HA is a useful preoperative liver function test as well as ICGR15%. Preoperative HA levels <100 ng/mL and ICGR15% <20% might be helpful indicators for major liver resection. We also recommend that HA measurement for evaluating liver function in the patients with obstructive jaundice ICG is not helpful.

Accelerated rehabilitation with early postoperative oral feeding following gastrectomy.

BACKGROUND/AIMS: To evaluate the safety and efficacy of early oral feeding in patients undergoing gastrectomy. METHODOLOGY: One hundred patients undergoing gastrectomy were studied. Patients in the early oral feeding group (Early group) began a liquid diet within 48 hours after operation and patients within the Traditional group received nothing by mouth until the resolution of the ileus. All of the patients were monitored for vomiting, abdominal distention, length of ileus, tolerance of regular diet, duration of intravenous fluid administration, length of hospitalization, and complications. RESULTS: The time to flatus was 55.5+/-12.5 hours and 78.0+/-22.2 hours in the Early and Traditional group, respectively (p<0.05). And fasting period was 2.14+/-1.08 days and 5.93+/-2.35 days in the Early and Traditional group, respectively (p<0.05). In addition, duration of intravenous fluid administration was shorter in the patients in the Early group compared with Traditional group (5.7+/-1.7 days vs. 9.2+/-3.9 days, p<0.05). As a result, length of postoperative hospitalization in the patients in the Early group was significantly shorter than those in the Traditional group (16.2+/-5.3 days vs. 23.4+/-9.8 days, p<0.05). The incidence of complications including nausea, vomiting, anastomotic leak and wound infection occurred equally in both groups. CONCLUSIONS: Early oral feeding after gastrectomy is safe, with no evidence of increased morbidity, and early postoperative oral feeding is also highly effective in reducing hospital stay.

Double duct-to-mucosa pancreaticojejunostomy for bifid pancreatic duct.

We report a pancreaticojejunostomy with double duct-to-mucosa anastomotic technique after pyloruspreserving pancreaticoduodenectomy for chronic pancreatitis with bifid pancreatic duct. A 49-year-old Japanese man was diagnosed preoperatively as having chronic pancreatitis with common bile duct stricture and pseudocyst of the pancreatic head. In a pancreaticoduodenectomy, the main pancreatic duct (7mm in diameter) and a secondary pancreatic duct (4mm in diameter) were identified intraoperatively at the transected surface. Pancreatography showed the main pancreatic duct as well as thesecondary pancreatic duct that drained the remaining dorsal pancreas, allowing us to diagnose bifid pancreatic duct. The pancreaticojejunostomy was performed in an end-to-side manner to create double duct-to-mucosa anastomoses and to approximate the pancreatic parenchyma and jejunal seromuscular layers. Although bifid pancreatic duct is a rare anatomical anomaly, it behooves every surgeon who performs pancreatic resections to be aware of this entity and the techniques for dealing with it.

Hepatocellular carcinoma in a case of Dubin-Johnson syndrome treated successfully with a central bilateral segmentectomy.

A 72-year-old woman with hepatocellular carcinoma and HCV cirrhosis combined with Dubin-Johnson syndrome was successfully treated by a central bilateral segmentectomy. While the preoperative serum bilirubin level is one of the established criteria for determining the indications for a hepatic resection, it is not effective for HCV cirrhosis cases associated with Dubin-Johnson syndrome. Postoperative hyperbilirubinemia may be cured without special treatment such as bilirubin absorption or plasma exchange, but such patients must be carefully observed to ensure that liver failure does not occur.

Analysis of the prognostic factors for liver metastasis of gastric cancer after hepatic resection: a multi-institutional study of the indications for resection.

BACKGROUND/AIMS: The number of reports of hepatic resection for metastatic gastric cancer is very small. The outcome and indications of hepatic resection for metastatic gastric cancer remains unknown. METHODOLOGY: A multi-institutional study was made. Thirty-six patients who underwent a hepatic resection for liver metastasis of gastric cancer with no residual tumor were included in this study. The clinicopathological factors were examined as prognostic factors by multivariate analyses. Thirty patients had recurrence and the recurrence pattern and risk factors for extrahepatic recurrence was examined. RESULTS: The overall survival rate was 64% at 1 year, 43% at 2 years, 26% at 3 years 26% at 5 years, and 26% at 10 years after hepatectomy. Multivariate analysis showed that lymphatic invasion, venous invasion of cancer cells of primary gastric cancer and the number of the liver metastasis (> 3) were independent poor prognostic factors after hepatic resection. The most common recurrence pattern was intrahepatic recurrence in 22 patients (73%). The risk factors for extrahepatic recurrence was serosal invasion, lymph node metastasis of primary gastric cancer, stage, and curability of operation. CONCLUSIONS: Hepatic resection for liver metastasis should be attempted in case primary gastric cancer has neither lymphatic invasion nor venous invasion. The most common recurrent site was the liver. In patients with advanced gastric cancer, having neither serosal invasion nor lymph node metastasis, who underwent a less curative operation, the intra-hepatic recurrence would be expected. Thus, aggressive adjuvant chemotherapy through the hepatic artery may improve the survival after hepatectomy in these patients.

Low-dose cisplatin plus oral tegafur and uracil for the treatment of lung metastases of hepatocellular carcinoma.

BACKGROUND/AIMS: An effective treatment for unresectable multiple lung metastases of hepatocellular carcinoma have never been established. METHODOLOGY: Six patients received the chemotherapy described herein as an initial treatment for lung metastases of hepatocellular carcinoma. Low-dose cisplatin infusion plus oral tegafur and uracil administration combination therapy essentially consisted of cisplatin (10 mg/day over 1 hour) infused on days 1-5 every week and oral tegafur and uracil (300 mg/day) administrated every day. This treatment was repeated weekly for essentially 4 consecutive weeks. RESULTS: Complete response was observed in no cases and partial response in 3 cases, while no change was observed in 4 cases and progressive disease in one case. An overall response rate was 50%. The serum alpha-fetoprotein and des-Y-carboxyprothrombin were reduced in most of the patients. Leukopenia of grade 2 was observed in only 1 (17%) patient. Thrombocytopenia of grade 2 was observed in 2 (33%) patients. Nausea (up to Grade 2) was occurring in 4 (67%) patients. Three patients with no other distant metastasis survive more than two years after lung metastasis, and the quality of life of these patients are well preserved. CONCLUSIONS: Low-dose cisplatin infusion combined with oral tegafur and uracil administration for the treatment of lung metastases of hepatocellular carcinoma may be an effective regimen with a high response rate and acceptable toxicities, although a larger study will be necessary to confirm the efficacy.

Surgical strategy to save patients with colon perforation with chronic renal failure on long-term hemodialysis.

BACKGROUND/AIMS: The aim of the current study is to clarify a strategy to save patients with diffuse peritonitis due to colonic perforation, who have been undergoing long-term hemodialysis with chronic renal failure. METHODOLOGY: Five patients with colon perforation with chronic renal failure on long-term hemodialysis were studied and their clinical courses and outcomes after surgical treatment were investigated. RESULTS: The proportion of salvage for patients in our cases was 60%. The chief reasons of failure in salvage in two patients were mainly a delay of surgical treatment and the compromised condition with recurrence of the neoplasm. In the current study, level of serum concentration of C-reactive protein of the patients on admission was found not to be reliable to decide a surgical indication, and delay of the surgical treatment was fatal. CONCLUSIONS: The physical examination is most important and reliable to decide the surgical indication for patients with colon perforation, and even with suspicion of peritonitis requiring a laparotomy, an immediate surgical treatment should be courageously performed for patients with chronic renal failure on long-term hemodialysis.