Perforated Duodenal Diverticulum With Postoperative Diverticulum Bleeding Successfully Treated Using Transcatheter Arterial Embolization.

A diverticulum is a relatively common finding that is generally discovered incidentally; it is most commonly observed in the colon, followed by the duodenum. However, duodenal diverticulum perforation (DDP) is a rare complication. Due to its rarity, its diagnosis is often challenging and the appropriate treatment remains unclear, possibly contributing to its high mortality rate. Traditionally, surgical repair is the primary mode of treatment. However, with the recent advancements in medical technology, conservative management such as bowel rest and endoscopic drainage help successfully manage DDP. Duodenal diverticulum bleeding (DDB) is a rare cause of upper gastrointestinal bleeding. While endoscopic, angiographical, and surgical treatments have been performed to achieve hemostasis, there is no consensus regarding the optimal treatment for DDB. We describe a case of a perforated duodenal diverticulum (DD) with postoperative diverticulum bleeding. Our patient, an elderly female, complained of abdominal pain. Computed tomography images revealed free air in the retroperitoneum, and gastrointestinal perforation was suspected. During the emergency surgery, a perforated DD was detected in the third portion of the duodenum. Due to severe inflammation, diverticulectomy was not performed as it was deemed risky. Instead, we directly sutured the orifice using an omental patch. Duodenal leakage was observed from postoperative day (POD) 3 with bleeding from the remnant DD occurred on PODs 6 and 13. An attempt at endoscopic hemostasis failed, but transcatheter arterial embolization (TAE) was successfully performed. The postoperative course was complicated, and the patient died on POD 54. To the best of our knowledge, this is the first report on DD perforation with postoperative DDB. The remnant DD may be damaged by the digestive juices and result in bleeding. Precautionary measures for duodenal leakage should be undertaken when the DD is unresectable. Additionally, TAE is effective for postoperative DDB.

[A case of recurrence with liver metastasis after total gastrectomy for StageIA gastric carcinoma successfully treated with S-1/CDDP combination followed by S-1 chemotherapy].

A 72-year-old man underwent total gastrectomy for gastric carcinoma. Postoperative staging was Stage IA. One year after operation, abdominal CT revealed a metastatic tumor in the left lateral posterior segment of the liver. He was given S-1/ CDDP combination chemotherapy(S-1 120mg/body, day 1-21, CDDP 95mg/body, day 8)every 5weeks as first-line treatment. After 2 courses of the treatment, the liver tumor was not detected by PET-CT. The clinical response was assessed to be complete response. After total 5 courses of the treatment, we changed to a single administration of S-1(120mg/body, day 1- 14)every 3 or 4 weeks as second-line chemotherapy. The effect has been continued for 18 months after the initial metastasis. S-1/CDDP and S-1 chemotherapy are effective for metachronous liver metastasis from gastric carcinoma, although prognosis of the disease is poor.

Perioperative blood transfusion and survival following curative hepatic resection for hepatocellular carcinoma.

BACKGROUND/AIMS: The association between transfusion and recurrence after resection for hepatocellular carcinoma (HCC) is still under debate. The influences of perioperative blood transfusion on survival and recurrence after curative hepatic resection for HCC and prognostic factors in patients with blood transfusion were evaluated. METHODOLOGY: Curative hepatectomy was performed in 210 patients (57%) with and 158 (43%) without perioperative blood transfusion. Prognostic factors were evaluated by univariate and multivariate analysis using Cox's proportional hazards model. RESULTS: Multivariate analysis revealed that perioperative blood transfusion was an independent predictor for recurrence in patients with serum low albumin level (< 3.5 g/dL). In transfused group, stage IV, large tumor size (> or = 5 cm), high value of ICGR15 (> or = 20%), and old age (> or = 60 year) were independent factors of poor disease-free survival. CONCLUSIONS: Perioperative blood transfusion promotes the recurrence of HCC after hepatic resection in patients with hypo-albuminemia. In transfused patients, establishment of strategy for recurrence based on pTNM staging, tumor size, ICGR15, and age may be required to improve survival.

Risk factors of long-term survival and recurrence after curative resection of hepatocellular carcinoma.

BACKGROUND/AIMS: The independent risk factors contributing to long-term survival (> or = 10-year survival rate) and recurrence after curative hepatic resection for hepatocellular carcinoma (HCC) were evaluated. METHODOLOGY: The prognoses were retrospectively analyzed in 247 consecutive patients (187 men and 60 women) treated with curative hepatic resection for HCC and discharged from the hospital. Prognostic factors were evaluated by multivariate analysis using Cox's proportional hazards model. RESULTS: Multivariate analysis revealed that pTNM stage IV, indocyanine green retention rate at 15 minutes (ICGR15) of > or = 20%, tumor size of > or = 5 cm, and positive hepatitis B surface antigen were independent risk factors of overall survival. Stage IV and ICGR15 of > or = 20% were also independent risk factors of disease-free survival. CONCLUSIONS: pTNM stage and ICGR15 may be simple and useful predictors to improve long-term survival and recurrence after curative hepatic resection for HCC.

Risk factors of intrahepatic recurrence after curative resection of hepatocellular carcinoma.

BACKGROUND/AIMS: Although the risk factors for the development of intrahepatic recurrence after hepatectomy for hepatocellular carcinoma (HCC) have been widely studied, little attention has been given to the prognostic factors affecting such patients. METHODOLOGY: Intrahepatic recurrence occurred in 105 (56%) of 188 patients who underwent curative hepatic resection of HCC and were discharged from the hospital. Among them, 17 (16%) also had simultaneous extrahepatic recurrence. Independent prognostic factors were evaluated by multivariate analysis using Cox's proportional hazards model. RESULTS: Multivariate analysis revealed that presence of extrahepatic recurrence, hepatitis B, and non-surgical treatments for recurrence were independent predictors of poor overall survival after initial hepatic resection or after recurrence. Risk factors of extrahepatic recurrence were young age, solitary and large HCC, high hepatitis activity, and large amount of intraoperative blood loss and blood transfusion. CONCLUSIONS: Survival of patients with intrahepatic recurrent HCC after resection should be stratified by the type of recurrence, type of hepatitis, and type of treatment for recurrence.

[Complete disappearance with oral UFT administration of recurrent hepatocellular carcinoma of the remnant liver and multiple lung metastasis after hepatic resection].

UFT is an anti-cancer drug which combines uracil with tegafur at a mole rate of 1:4, and shows a high anti-tumor effect by raising the 5-FU level in a tumor. A 55-year-old man with hypochondriac pain was admitted to Shinshu University Hospital. The preoperative diagnosis was giant hepatocellular carcinoma (HCC) of the right hepatic anterior region, and extended anterior segmentectomy of the liver was performed. Three months later, serum alpha-fetoprotein (AFP) and PIVKA-II were elevated markedly, and computed tomography (CT) and magnetic resonance imaging (MRI) revealed a recurrence in the remnant liver and multiple lung metastasis. Chemotherapy with oral UFT (300 mg/day) administration alone was started for the unresectable HCC. Three months later, CT and MRI showed complete disappearance of the recurrent HCC and multiple lung metastasis. Also, the titers of AFP and PIVKA-II were reduced to normal levels. This case suggests that oral UFT administration is a safe and effective therapy for postoperative HCC, even with lung metastasis.