The impact of antithrombotic therapy in patients undergoing emergency laparoscopic cholecystectomy for acute cholecystitis - A single center experience.

AIM: The risk of developing hemorrhagic complications during or after surgery in patients receiving antithrombotic therapy remains uncertain. Moreover, the impact of antithrombotic therapy under an acute inflammatory status is unclear. We investigated the impact of antithrombotic therapy in patients undergoing emergency laparoscopic cholecystectomy for acute cholecystitis. METHODS: This record-based retrospective study included patients who underwent emergency laparoscopic cholecystectomy for acute cholecystitis between September 2015 and January 2019. Patients who received elective laparoscopic cholecystectomy, open cholecystectomy, or gallbladder drainage before surgery were excluded. We evaluated the diseases for which antithrombotic therapy was administered, background characteristics, laboratory parameters and perioperative outcomes of patients with acute cholecystitis. The primary outcomes were intraoperative bleeding, blood transfusion requirement, conversion to an open procedure, and postoperative complications, including bleeding. RESULTS: One hundred and twenty-one patients (non-antithrombotic therapy, n = 92; antithrombotic therapy, n = 29) were analyzed. There were differences in age and American Association of Anesthesiologists class (P < .05), but not in the grade of acute cholecystitis (P = .19). There were no differences in the operation time (non-antithrombotic vs antithrombotic therapy: 142 [58-313] vs 146 minutes [65-373], P = .85), bleeding (17.5 mL [1-1400] vs 25 mL [1-1337], P = .58), blood transfusion requirement (n = 3 [3.2%] vs n = 2 [6.9%], P = .59) and the number of cases converted to open surgery (n = 8 [9%] vs n = 2 [7%], P = 1). The rates of postoperative complications, including bleeding, did not differ between the two groups and there was no mortality in either group. CONCLUSION: Emergency laparoscopic cholecystectomy could be planned for patients receiving single antithrombotic therapy, similar to patients who were not receiving antithrombotic therapy.

Acute appendicitis associated with the presence of schistosome eggs in a sailor: a case report.

BACKGROUND: Schistosomiasis is prevalent in tropical and subtropical areas and rarely reported in developed countries. Schistosomiasis often occurs as a chronic illness, which can cause liver and intestinal damage. Appendicitis is an unusual complication of schistosomiasis. We herein present a case of acute appendicitis associated with the presence of schistosome eggs in a sailor from the Philippines. CASE PRESENTATION: A 34-year-old Filipino man who worked as a sailor presented to our hospital with a 2-day history of acute right lower quadrant abdominal pain and fever. A physical examination revealed right lower quadrant abdominal pain with signs of peritoneal irritation, including rebound tenderness. Computed tomography revealed thickening of the appendix associated with mural calcification and fluid collection around the cecum. Based on these findings, the preoperative diagnosis was acute appendicitis. Laparoscopic appendectomy was performed. Swelling of the appendix and contaminated ascites were observed intraoperatively, but there was no evidence of appendiceal perforation. A histopathological examination showed inflammation of the appendix wall and numerous ovoid bodies present within the submucosa, many of which were calcified. Severe infiltration of lymphocytes and fibrosis were recognized around the oval bodies. The numerous oval bodies were morphologically consistent with schistosomiasis. The final diagnosis was acute phlegmonous appendicitis associated with the presence of schistosome eggs. We examined the patient for signs of adult worm activity, but the results of stool ova and parasite examinations performed twice were negative. He was discharged and returned to his country on postoperative day 9. CONCLUSIONS: The incidence of schistosomal appendicitis, which is seldom reported in developed countries, is expected to increase in Japan in the near future. Clinicians should suspect schistosome eggs as a cause of acute appendicitis in patients who have emigrated from or are traveling from endemic areas, and when mural calcification of the appendix is observed on imaging.

The Impact of Low Muscle Mass in Patients Undergoing Emergency Surgery for Colonic Perforation - A Single-center Experience.

AIM: The aim was to analyze the correlation between psoas muscle mass and mortality, as well as postoperative complications in patients treated for colonic perforation. PATIENTS AND METHODS: A total of 46 patients met the study criteria. Patients were classified into an elderly (age, ≥75 years, n=24) and a younger group (age, <75 years, n=22). Background factors, postoperative data (including duration of hospital stay and discharge) were collected. The cross-sectional area of the psoas muscle area (PMA) was measured on the same day of operation. RESULTS: The age/length of stay and PMA were significantly correlated in the younger group (p=0.0015, 0.023, respectively). Fifteen and six patients were discharged to return home, and 8 and 16 patients were transferred to another hospital, in the younger and elderly groups, respectively (p=0.02). Discharge was not correlated with the PMA in either group. CONCLUSION: The total psoas muscle mass would be useful as a quick and convenient measure of sarcopenia in younger patients, but not elderly patients.

The long-term survival in primary retroperitoneal mucinous cystadenocarcinoma: a case report.

BACKGROUND: Primary retroperitoneal mucinous cystadenocarcinoma (PRMC) is extremely rare, and its biological behavior, pathogenesis, optimum treatments, and prognosis remain to be elucidated. We herein report a case of PRMC with an 80-month follow-up. CASE PRESENTATION: A 29-year-old woman was diagnosed with unknown retroperitoneal tumor with benign right ovarian cyst and uterine fibroids, and she underwent laparotomy. The tumor was completely resected with a subsequent histopathological diagnosis of primary retroperitoneal mucinous cystadenocarcinoma (PRMC). Eighty months after surgery, she remains recurrence-free. CONCLUSION: PRMC is an extremely rare tumor. Only around 60 cases have so far been published in the literature. The preoperative diagnosis of PRMC is difficult, and a definitive diagnosis can usually only be made based on the findings of histopathological examinations after surgery. Presently, only radical resection is useful for both diagnostic and therapeutic purposes. The optimal long-term management after surgery is still not well established. Further studies on PRMC are therefore needed to elucidate the etiology and establish effective treatments.

Gallbladder small cell carcinoma: a case report and literature review.

Gallbladder small cell carcinoma (SCC) comprises only 0.5 % of all gallbladder cancer and consists of aggressive tumors with poor survival outcomes against current treatments. These tumors are most common in elderly females, particularly those with cholecystolithiasis. We report the case of a 79-year-old woman with gallbladder small cell carcinoma. The patient had intermittent right upper quadrant abdominal pain and was admitted to our hospital due to suspected acute cholecystitis. She regularly received medical treatment for diabetes, hypertension, and dyslipidemia. On initial laboratory evaluation, the levels of aspartate aminotransferase (AST), total bilirubin, and C-reactive protein (CRP) were markedly elevated. She underwent computed tomography (CT) for screening. CT images showed a thick-walled gallbladder containing multiple stones and multiple 3-cm-sized round nodular lesions, which were suggestive of metastatic lymph nodes. After percutaneous transhepatic gallbladder drainage was performed, endoscopic ultrasound-guided fine needle aspiration of enlarged lymph nodes resulted in a diagnosis of small cell carcinoma or adenocarcinoma. However, we could not identify the primary lesion before the surgery because of no decisive factors. We performed cholecystectomy because there was a possibility of cholecystitis recurrence risk and also partial liver resection because we suspected tumor invasion. The final pathological diagnosis was neuroendocrine carcinoma of the gallbladder, small cell type. The tumor stage was IVb, T3aN1M1. The patient died 13 weeks after the surgery. In the present paper, we review the current available English-language literature of gallbladder SCC.

Multidisciplinary therapy for granulocyte-colony-stimulating factor producing carcinosarcoma of the esophagus: report of a case.

The granulocyte-colony-stimulating factor (G-CSF)-producing esophageal carcinosarcoma is extremely rare in esophageal cancer. In the present case, multidisciplinary therapy, which is surgical resection with preoperative chemotherapy, has been effectively treatment to granulocyte-colony-stimulating factor producing esophageal carcinosarcoma of the esophagus.

Case of plasmablastic lymphoma of the sigmoid colon and literature review.

Plasmablastic lymphoma (PBL) is a rare form of non-Hodgkin's lymphoma that is associated with human immunodeficiency virus (HIV) infection. Although PBL is most commonly observed in the oral cavity of HIV-positive patients, it can also be observed at extra-oral sites in HIV-negative patients. This report represents an unusual case of HIV-negative PBL that occurred in the sigmoid colon. This patient had a history of systemic lupus erythematosus and an underlying immunosuppressive state from long term steroid therapy. The lymphoma cells were positive for CD138, kappa light chain restriction and Epstein-Barr virus and negative for CD20/L26, CD3, CD79a, UCHL1 (CD45RO) and cytokeratin (AE1/AE3). The patient died approximately 2 mo after the operation. In the present paper, we review cases of PBL of the colon in HIV-negative patients.

Endoscopic Sphincterotomy Using the Rendezvous Technique for Choledocholithiasis during Laparoscopic Cholecystectomy: A Case Report.

A 50-year-old male was examined at another hospital for fever, general fatigue and slight abdominal pain. He was treated with antibiotics and observed. However, his symptoms did not lessen, and laboratory tests revealed liver dysfunction, jaundice and an increased inflammatory response. He was then admitted to our hospital and underwent an abdominal computed tomography scan and magnetic resonance cholangiopancreatography (MRCP), which revealed common bile duct (CBD) stones. He was diagnosed with mild acute cholangitis. As the same time, he was admitted to our hospital and an emergency endoscopic retrograde cholangiopancreatography was performed. Vater papilla opening in the third portion of the duodenum and presence of a peripapillary duodenal diverticulum made it difficult to perform cannulation of the CBD. In addition, MRCP revealed that the CBD was extremely narrow (diameter 5 mm). We therefore performed laparoscopic cholecystectomy and endoscopic sphincterotomy using the rendezvous technique for choledocholithiasis simultaneously rather than laparoscopic CBD exploration. After the operation, the patient was discharged with no complications. Although the rendezvous technique has not been very commonly used because several experts in the technique and a large operating room are required, this technique is a very attractive and effective approach for treating choledocholithiasis, for which endoscopic treatment is difficult.

Management of peripheral neuropathy induced by nab-paclitaxel treatment for breast cancer.

Nanoparticle albumin-bound paclitaxel (nab-PTX) is a key drug used in breast cancer treatment which often causes chemotherapy-induced peripheral neuropathy (CIPN). No effective approach for CIPN control has been established to date. This study assessed a new approach to CIPN integrating two concepts: compression therapy using stockings and sleeves, and medication therapy using selected prophylactic drugs, including goshajinkigan, which we named the "3S" approach. Fourteen breast cancer patients were divided into a 3S group (n=7) and a control group (n=7), and were treated with 260 mg/m(2) of nab-PTX once every three weeks. CIPN initially developed in five control-group patients and one 3S-group patient (p=0.03). Across all cycles, the CIPN grades, as determined by the Common Terminology Criteria for Adverse Events (CTCAE), were significantly lower in the 3S group than in the control group (p<0.001). The mean nab-PTX dose in the 3S group was 77.1 mg/m(2)/week versus 64.7 mg/m(2)/week in the control group (p<0.01). By controlling the development and severity of CIPN, 3S treatment appears to support the use of the recommended nab-PTX dosing for breast cancer patients.

The impact of hepatic denervation on the accumulation of hepatic progenitor cells during liver regeneration in rats.

BACKGROUND/AIMS: All autonomic hepatic nerves are transected following liver transplantation. Recent studies have shown the relationship between an inhibition of autonomic nerves and the accumulation of hepatic progenitor cells (HPC). This study aims to elucidate the influence of hepatic denervation on the accumulation of HPC in the process of liver regeneration. METHODOLOGY: Male Sprague-Dawley rats underwent hepatic denervation. Immediately after either denervation (DN group, n=30) or a sham operation (control group, n=30), a two-thirds hepatectomy was performed, and these were sacrificed chronologically. An immunohistochemical analysis of HPC was performed with a mouse monoclonal OV6 type antibody. RESULTS: The liver per body weight ratio gradually increased in both groups. On postoperative day (POD) 7, the DN group showed a significantly higher ratio. The HPC expression gradually increased in both groups. The maximal HPC number was observed on POD 7 in the DN group and on POD 3 in the control group. Although there was no significant difference in the HPC numbers between the DN and control group until POD 3, the number of HPC were significantly higher in livers of the denervated rats than in those of the sham operated rats between POD 5 and 14. CONCLUSIONS: The hepatic autonomic nerves were thus suggested to play an important role in the accumulation of HPC during liver regeneration in rats.

Liver repopulation by transplanted hepatocytes in a rat model of acute liver failure induced by carbon tetrachloride and a partial hepatectomy.

BACKGROUND: Although hepatocyte transplantation holds great promise, most of the transplanted hepatocytes fail to proliferate in the liver without any manipulation of the host. Previous studies have shown that the replacement of the host liver cells with transplanted hepatocytes, called "liver repopulation", requires a combination of proliferative stimuli to the transplanted hepatocytes and suppression of the host hepatocytes. This study explored whether liver repopulation could be achieved by hepatocyte transplantation in a chemically and surgically induced-liver failure model in the rat. MATERIAL/METHODS: Dipeptidyl peptidase IV-positive (DPPIV +) Fisher rats were used as donor and syngeneic DPPIV-deficient (DPPIV-) rats served as recipient. The recipient rats were treated with carbon tetrachloride (CCl4) for 4 weeks followed by a 68% partial hepatectomy (PH) and transplantation of the hepatocytes (HT). Five groups were established based on the influence of specific factors including CCl4, PH, and HT. The liver regeneration rates were evaluated by the liver weight/body weight (LW/BW) ratio. The liver repopulation rates were determined by the formula; (DPPIV+ cell counts/all cell counts) ×100%. RESULTS: The liver regeneration rates were 3.5 and 2.6 in the rats with CCl4+PH, and PH alone, respectively (P<0.01). In the rats with CCl4+PH, DPPIV positive cell clusters appeared in the host liver parenchyma 7 days after HT (day 7), exhibiting continuous proliferation up to day 28 (The liver repopulation rates were 1.1% and 13.4%, respectively, p<0.05). CONCLUSIONS: Liver repopulation by hepatocyte transplantation was therefore found to be possible in partially hepatectomized rats under the continuous exposure to regulated doses of CCl4.

MRI can determine the adequate area for debridement in the case of Fournier's gangrene.

A 57-year-old man was transferred to our hospital because of gluteal pain. His right buttock had flare and swelling. Complete blood count showed leukocytosis, and renal failure was evident. Pelvic computed tomography (CT) revealed that the abscess, including gas, was widespread into the hypodermal tissue of the right buttock. Fournier's gangrene had been suspected, and immediate drainage was performed on the right buttock. The symptom and the condition improved rapidly, but on the day after the operation, the patient became drowsy and fell into endotoxic shock. Magnetic resonance imaging (MRI) revealed strong inflammation along the entire fascia of the right femur and necrotizing fasciitis. MRI was very useful for identification of the necrotic range. Immediately, an emergency operation was performed; 3 wide incisions were made on the right thigh and crus for drainage. The patient was cared for intensively under a sedated condition, and irrigation and debridement were repeated every day. Culture of the pus revealed mixed infection of Escherichia coli and anaerobic bacteria, and a large quantity of antimicrobial drug was used. The inflammatory reaction decreased, and the patient's general condition tentatively improved. With Fournier's gangrene, initiating adequate surgical and medical treatment is essential. Therefore, MRI should be used in the early exact diagnosis of this disease to obtain knowledge of the extent of necrosis and to determine the adequate area for debridement.

Efficacy and limitation of bone marrow transplantation in the treatment of acute and subacute liver failure in rats.

AIM: Recent reports have shown that bone marrow cells (BMC) retain the potential to differentiate into hepatocytes. Thus, the BMC have been recognized as an attractive source for liver regenerative medicine. However, it has not been clarified whether BMC transplantation can be used to treat liver damage in vivo. In the present study, we explored whether BMC possess therapeutic potential to treat acute and/or subacute liver failure. METHODS: Fulminant hepatic failure (FHF) was induced by 70% hepatectomy with ligation of the right lobe pedicle (24% liver mass), followed by transplantation of BMC into the spleen. Dipeptidyl peptidase IV-positive (DPPIV(+)) BMC were then transplanted into DPPIV-negative (DPPIV(-)) recipients following hepatic irradiation (HIR) in which 70% of the liver was resected and the remnant liver irradiated. RESULTS: There was no benefit of BMC transplantation towards survival in the FHF model. DPPIV(+) hepatocytes appeared in the liver tissues of the DPPIV(-) HIR model rats, but DPPIV(+) hepatocytes replaced less than 13% of the recipient liver. CONCLUSION: BMC transplantation may have limitations in the treatment of fulminant or acute liver failure because they do not have sufficient time to develop into functional hepatocytes. Preparative HIR may be beneficial in help to convert the transplanted BMC into host hepatocytes, and provide a survival benefit. Although, However, the precise mechanism warrants further studies.

Acute deterioration of idiopathic portal hypertension requiring living donor liver transplantation: a case report.

Case reports of severe idiopathic portal hypertension (IPH) requiring liver transplantation are very rare. We report the case of a 65-year-old woman who was diagnosed as having IPH. At the age of 60 years, her initial symptom was hematemesis, due to ruptured esophageal varices. Computed tomography of the abdomen showed splenomegaly and a small amount of ascites, without liver cirrhosis. She was diagnosed as having IPH and followed-up as an outpatient. Five years later, she developed symptoms of a common cold and rapidly progressive abdominal distension. She was found to have severe liver atrophy, liver dysfunction, and massive ascites. Living donor liver transplantation was then performed, and her postoperative course was uneventful. Histopathological findings of the explanted liver showed collapse and stenosis of the peripheral portal vein. The areas of liver parenchyma were narrow, while the portal tracts and central veins were approximate one another, leading to a diagnosis of IPH. There was no liver cirrhosis. The natural history of refractory IPH could be observed in this case. Patients with end-stage liver failure due to severe IPH can be treated by liver transplantation.

Multicentric occurrence and spread of hepatocellular carcinoma in whole explanted end-stage liver.

AIM: Hepatocellular carcinoma (HCC) arising from the end stages of liver cirrhosis is a fair indication for liver transplantation (LT). To pathologically investigate the multicentric occurrence of relatively early staged HCC in cirrhosis, we studied whole explanted livers. METHODS: Fourteen explanted livers from patients undergoing living donor LT (LDLT) were examined. The stage of the HCCs was judged to be within the Milan criteria (M-C; a single HCC less than 5 cm or three HCCs less than 3 cm). Histological examination was performed using serially sectioned specimens 5-7 mm in width. Characterization of preoperatively detectable and undetectable lesions was also performed. RESULTS: In nine patients (64.3%), a total of 34 nodules were found after whole liver histological examination (WLHE). In five patients (31%), the results exceeded the M-C. The characteristics of undetectable HCCs included a minute (median size 6 mm), well-differentiated appearance (80%), with indistinct margins (85.3%) and without vascular invasion (94%). There was no recurrence in any patients at the time of follow up (median follow-up period, 30.1 months). CONCLUSION: A multicentric occurrence of HCCs was demonstrated in cirrhotic livers with HCCs within the M-C. Undetectable HCCs in cirrhotic livers may have no impact on recurrence after LT.

Two-surgeon technique using saline-linked electric cautery and ultrasonic surgical aspirator in living donor hepatectomy: its safety and efficacy.

BACKGROUND: Saline-linked electric cautery (SLC) is introduced as an effective device to reduce blood loss in liver surgery. The aim of the current study was to evaluate the safety and efficacy of a 2-surgeon technique using SLC and the Cavitron Ultrasonic Surgical Aspirator (CUSA; Valleylab, Boulder, CO) in living donor hepatectomy. METHODS: Forty-three living donor right hepatectomy cases were enrolled in this study. The first 28 cases underwent liver transection with CUSA alone (CUSA group), while additional SLC was applied in the current 15 cases (2-surgeon technique, TS group). RESULTS: Blood loss was significantly reduced by the 2-surgeon technique (1,115.2 +/- 652.9 g in CUSA group vs 732.3 +/- 363.6 g in TS group, P < .05). In the TS group, there was no bile leakage from the cut surface. The early graft function and postoperative recipient survival were not significantly different between the groups. CONCLUSIONS: According to our single-center experience, blood loss and donor complications in living donor hepatectomies were significantly reduced using a 2-surgeon technique using CUSA and SLC, while maintaining the graft viability.

Metabolism for cyclosporin A during liver regeneration after partial hepatectomy in rats.

AIM: To elucidate the metabolism and the effect of the cyclosporin A (CyA) as a representative immunosuppressive drug used in transplantation in a partially hepatectomized rat model. METHODS: CyA was administered to rats that underwent a 70% hepatectomy. These rats were randomly assigned into three groups according to the dose of CyA administration as follows; (group 1) water, (group 2) 5 mg/kg CyA, (group 3) 10 mg/kg CyA. On postoperative days-1, 3, 7 and 14, the rats were killed to analyze the serum concentration of CyA, the liver regeneration ratio, biochemical or histological markers, and mRNA expression using reverse transcriptase-polymerase chain reaction method to determine albumin and cytochrome p450 expression. RESULTS: The serum concentration of CyA in group 3 was significantly higher than group 2 during liver regeneration. CyA enhanced the liver regeneration in a dose dependent manner. The mRNA expression associated with CyA metabolism was significantly decreased on day 14, while preserving the albumin producing activity. CONCLUSION: These data indicate that the p-450 activity required to metabolize the CyA may be reduced during regeneration of the remnant liver after a hepatectomy, which may, therefore, be linked to difficulty in controlling the optimal dose of CyA during early period of LDLT.

Compressive stenosis of the inferior vena cava due to localized ascites after living-donor liver transplantation.

A 54-year-old woman was admitted to our hospital following the diagnosis of decompensated liver cirrhosis with hepatitis C. She underwent living-donor liver transplantation, performed using the left hepatic lobe with the middle hepatic vein donated by her husband. After the transplantation, the patient suffered from massive ascites with liver dysfunction. Computed tomography demonstrated stenosis of the suprahepatic inferior vena cava (IVC) with focal collection of fluid. A second laparotomy was performed 19 days after the transplantation. When the encapsulated localized ascites on both sides of the IVC was opened, the ascites was flushed away. Subsequently, the grafted liver was easily mobilized and it was placed in the natural position without any tension, and the pressure gradient of the IVC was improved. Herein, we report a very rare case of compression stenosis of the IVC resulting in Budd-Chiari syndrome caused by localized encapsulated ascites.

Significance of the serum level of soluble E-cadherin in patients with HCC.

BACKGROUND/AIMS: E-cadherin (E-cad) is a type of adhesion molecule, and recent studies have demonstrated a correlation between its expression in tumor lesions and the recurrence of HCC. Serum levels of soluble E-cad are significantly elevated in patients with several types of cancer. The authors evaluated the significance of the serum level of soluble E-cad as a predictor of early recurrences (intrahepatic or extrahepatic metastasis) of HCC after a curative resection. METHODOLOGY: The concentrations of soluble E-cad in the serum of 25 HCC patients before surgery and 12 healthy subjects were measured using a sandwich enzyme-linked immunosorbent assay. The hepatic expression of E-cad was examined by immunohistochemical staining. RESULTS: The median serum soluble E-cad levels were significantly elevated in HCC patients before surgery in comparison to those in healthy subjects (10,759 ng/mL vs. 5,798 ng/mL, p < 0.05). The patients in the high serum soluble E-cad group experienced a higher incidence of early recurrence (p < 0.05). The levels of expression of E-cad in HCC lesions were not related to the serum levels of soluble E-cadherin. CONCLUSIONS: The study demonstrated that serum soluble E-cad levels were elevated in patients with HCC, and high serum soluble E-cadherin (> or = 8,000 ng/ml) was associated with early recurrence or extrahepatic metastasis. Serum soluble E-cad may therefore be a potential prognostic marker for HCC.