Treatment of delayed pancreatic fistula associated with anastomosis breakdown after pancreaticoduodenectomy using percutaneous interventions.

We here present a rare case of development of a postoperative pancreatic fistula and breakdown of the pancreaticojejunal anastomosis 8 months after pancreaticoduodenectomy. A 70-year-old man underwent pancreaticoduodenectomy for distal cholangiocarcinoma and initially recovered well. However, 8 months later, he developed abdominal pain and distention and was admitted to our institution with suspected pancreatitis. On the 17th day of hospitalization, he suddenly bled from the jejunal loop and a fluid collection was detected near the pancreaticojejunal anastomosis site. The fluid collection was drained percutaneously. Subsequent fistulography confirmed breakdown of the pancreaticojejunal anastomosis. Considering the patient's overall condition and the presence of postoperative adhesions, we decided to manage him conservatively. An additional drain tube was placed percutaneously from the site of the anastomotic breakdown into the lumen of the jejunum, along with the tube draining the fluid collection, creating a completely new fistula. This facilitated the flow of pancreatic fluid into the jejunum and was removed 192 days after placement. During a 6-month follow-up, there were no recurrences of pancreatitis or a pancreatic fistula. This case highlights the efficacy of percutaneous drainage and creation of an internal fistula as a management strategy for delayed pancreatic fistula and anastomotic breakdown following pancreaticoduodenectomy.

Efficient multiple treatments including molecular targeting agents in a case of recurrent hepatocellular carcinoma, post-living donor liver transplantation.

Despite the promising efficacies of recently developed molecular targeting therapies for hepatocellular carcinoma, their role in liver transplantation is unknown. Here we report that multidisciplinary treatment, including novel molecular targeting therapy with lenvatinib, achieved long-term survival of a patient with post-liver transplantation recurrence of hepatocellular carcinoma. A 62 year-old man with hepatocellular carcinoma beyond the Milan criteria, arising from hepatitis B virus-associated cirrhotic liver, underwent living donor liver transplantation. However, alpha-fetoprotein level increased a month post-transplantation, and pleural dissemination and lung metastasis of hepatocellular carcinoma in the right lung were detected. The patient was initially treated with sorafenib and rapamycin, right pleurectomy and upper and middle lobectomies were attempted as the second treatment. However, remnant tumors started to grow. Subsequently, the newly molecular targeting agents; regorafenib and lenvatinib, approved for recurrent hepatocellular carcinoma in Japan, were administered. Lenvatinib efficiently reduced tumor volumes and the alpha-fetoprotein level, which contributed to maintaining better quality of life for 26 months as an outpatient. Unfortunately, sepsis caused by cholangitis and liver abscess required the discontinuation of lenvatinib, and the patient died 73 months after the recurrence of hepatocellular carcinoma. Multidisciplinary treatment including lenvatinib is potentially acceptable for recurrent hepatocellular carcinoma after liver transplantation.

Evidence for a Common Origin of Homomorphic and Heteromorphic Sex Chromosomes in Distinct Spinacia Species.

The dioecious genus Spinacia is thought to include two wild relatives (S. turkestanica Ilj. and S. tetrandra Stev.) of cultivated spinach (S. oleracea L.). In this study, nuclear and chloroplast sequences from 21 accessions of Spinacia germplasm and six spinach cultivars or lines were subjected to phylogenetic analysis to define the relationships among the three species. Maximum-likelihood sequence analysis suggested that the Spinacia plant samples could be classified into two monophyletic groups (Group 1 and Group 2): Group 1 consisted of all accessions, cultivars, and lines of S. oleracea L. and S. turkestanica Ilj. and two of five S. tetrandra Stev. accessions, whereas Group 2 was composed of the three remaining S. tetrandra Stev. accessions. By using flow cytometry, we detected a distinct difference in nuclear genome size between the groups. Group 2 also was characterized by a sexual dimorphism in inflorescence structure, which was not observed in Group 1. Interspecific crosses between the groups produced hybrids with drastically reduced pollen fertility and showed that the male is the heterogametic sex (XY) in Group 2, as is the case in S. oleracea L. (Group 1). Cytogenetic and DNA marker analyses suggested that Group 1 and Group 2 have homomorphic and heteromorphic sex chromosome pairs (XY), respectively, and that the sex chromosome pairs of the two groups evolved from a common ancestral pair. Our data suggest that the Spinacia genus may serve as a good model for investigation of evolutionary mechanisms underlying the emergence of heteromorphic sex chromosome pairs from ancestral homomorphic pairs.