Bariatric Surgery as a Bridge to a Successful Kidney Transplantation: A Case Report.

BACKGROUND: Severe obesity impairs renal function and outcomes in kidney transplant recipients. Bariatric surgery benefits those unresponsive to medical treatments. Limited case reports exist on its efficacy and long-term prognosis for transplant candidates. Thus, this study aims to present a case in which laparoscopic sleeve gastrectomy was safely performed on a patient with severe obesity awaiting kidney transplantation. CASE PRESENTATION: This study included a dialysis patient with a body mass index of 47 kg/m2. Living-donor kidney transplantation using his younger sister as a donor was considered, but it was determined that the risk of complications during and after surgery was high. Medical treatment was first performed, but the obesity did not improve; therefore, a laparoscopic sleeve gastrectomy was performed. Although postoperative bleeding occurred, the patient was discharged from the hospital on the 14th postoperative day. Subsequently, his weight steadily decreased, and living-donor kidney transplantation was performed 13 months after laparoscopic sleeve gastrectomy was performed. Furthermore, the patient's progress after kidney transplantation was good, and he was freed from hemodialysis. CONCLUSION: Improving severe obesity before kidney transplantation is effective in improving prognosis, and bariatric surgery should be considered when medical treatment is ineffective. Future research are needed to determine the optimal time between the performance of this procedure and kidney transplantation, as well as the long-term prognosis after kidney transplantation.

Associating liver partition and portal vein ligation for staged hepatectomy as bridging therapy for liver transplantation in an infant with an advanced hepatic rhabdoid tumor.

BACKGROUND: Malignant rhabdoid tumors (MRTs) are rare, aggressive tumors that mainly affect children and currently lack effective chemotherapeutic regimens. Liver MRTs are particularly challenging to manage due to the difficulty of performing one-stage liver resection, and preemptive liver transplantation is associated with high recurrence rates. However, the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique offers a promising surgical approach for advanced-stage liver tumors where conventional liver resection is not feasible. CASE REPORT: A patient with a large liver rhabdoid tumor that had invaded the three main hepatic veins underwent four courses of cisplatin-pirarubicin chemotherapy. ALPPS was performed due to insufficient residual liver capacity, with hepatic parenchymal dissection between the anterior and posterior liver zones in the first stage of surgery. After confirming adequate remaining liver volume, the liver was resected except for S1 and S6 on postoperative day 14. LDLT was performed 7 months after ALPPS due to the gradual deterioration of liver function caused by chemotherapy. The patient was recurrence-free 22 and 15 months after ALPPS and LDLT, respectively. CONCLUSIONS: The ALPPS technique is a curative option for advanced-stage liver tumors that cannot be managed with conventional liver resection. In this case, ALPPS was used successfully to manage a large liver rhabdoid tumor. Then, liver transplantation was performed after chemotherapy. The ALPPS technique should be considered a potential treatment strategy for patients with advanced-stage liver tumors, particularly those who can undergo liver transplantation.

Fatal acquired coagulation factor V deficiency after hepatectomy for advanced hepatocellular carcinoma as a possible immune checkpoint inhibitor-related adverse event: a case report.

BACKGROUND: Atezolizumab plus bevacizumab therapy was recently introduced as the first line for unresectable advanced hepatocellular carcinoma (HCC), but immune-related adverse events (IrAEs) due to atezolizumab are a great concern. Here, we report the case of a patient who developed fatal acquired coagulation factor deficiency after hepatectomy for HCC, treated with atezolizumab and bevacizumab before surgery. CASE PRESENTATION: A 70-year-old man received right trisegmentectomy of the liver with hepaticojejunostomy for advanced HCC with bile duct invasion, after atezolizumab and bevacizumab therapy. The patient suffered the sudden onset of severe multiple coagulation factor deficiency (II, V, VII, VIII, IX, X, XI and XII) immediately following reoperation for anastomotic leakage of hepaticojejunostomy, 7 days after hepatectomy. The coagulation factor deficiency did not reverse even with intensive treatment, and the patient died of uncontrollable bleeding 32 days after hepatectomy. An IrAE due to atezolizumab was suspected because the patient had developed the possible IrAE of enthesitis of the right gastrocnemius muscle before surgery, and specific inhibitors against factor V and anti-factor V autoantibodies were detected, leading to an ultimate diagnosis of autoimmune FV/5 deficiency (AiF5D). CONCLUSION: Severe acquired coagulopathy should be recognized as a possible life-threatening IrAE when using atezolizumab and bevacizumab for HCC.

Human chorionic gonadotropin-ß promotes pancreatic cancer progression via the epithelial mesenchymal transition signaling pathway.

Background: The human chorionic gonadotropin free beta-subunit (hCGß) is ectopically produced in various epithelial cancers and is associated with poor prognoses. However, its molecular mechanism remains unclear. In this study, we examined the biological role of hCGß in pancreatic cancer progression. Methods: Tissue specimens of 30 patients with pancreatic cancer were examined immunohistochemically to investigate the relationship between hCGß expression and clinicopathological features. We also evaluated the molecular effects of hCGß-downregulated pancreatic cell lines. Results: Total of 21 cases were positive for immunostaining, and 17 of 25 metastatic lymph nodes were positive. hCGß expression levels were correlated with pancreatic cancer T and N factors. hCGß expression was significantly associated with poor overall and recurrence-free survival (P<0.001). In a multivariate analysis, hCGß expression was independently associated with overall survival (HR 14.0; 95% CI: 1.5-130; P=0.019). The proliferative, invasive, and migratory abilities of hCGß-downregulated cell lines were reduced compared with the control cell lines. Moreover, downregulation of hCGß reduced vimentin, slug, and α-smooth muscle actin expression and increased E-cadherin expression. Conclusions: hCGß expression is related to cancer progression and poor prognoses via epithelial mesenchymal transition. hCGß is a potential prognostic marker and molecular target in pancreatic cancer.

A Case of bilateral concomitant inguinal and femoral hernias treated with transabdominal preperitoneal repair.

Synchronous bilateral hernias are very rare, and subclinical hernias as this case are very difficult to diagnose preoperatively. Laparoscopic surgery, which can accurately confirm and reinforce the weakened bilateral inguinal region, was very useful.

Evaluation of circulating tumor DNA as a biomarker in pancreatic cancer with liver metastasis.

Pancreatic cancer is an aggressive, solid tumor, with a grave prognosis. Despite surgical treatment in patients with pancreatic cancer, the rate of recurrence is high. In addition, although tumor biomarkers are frequently used to confirm advanced pancreatic cancer, this is not accurate and the biomarkers currently used cannot indicate prognosis. This study sought to evaluate circulating tumor DNA as a tumor biomarker to prognosticate pancreatic cancer. Patients with advanced pancreatic cancer and liver metastasis (N = 104) were included, and blood samples were collected from all patients. The mutant allele frequency was measured using amplicon-based deep sequencing on a cell-free DNA panel covering 14 genes with > 240 hot spots. In patients with advanced pancreatic cancer, 50% (N = 52) had detectable ctDNA levels, with TP53 (45%, N = 47) and KRAS (42.3%, N = 44) mutations the most common. Patients with detectable circulating tumor DNA levels also had significantly worse overall survival and progression free survival than ctDNA negative patients (8.4 vs 16 months, P<0.0001 for overall survival; 3.2 vs 7.9 months, P<0.0001 for progression-free survival). In a multivariate analysis, ctDNA status was independently associated with overall survival and progression-free survival (HR = 3.1, 95%CI = 1.9-5.0, P<0.0001; HR 2.6, 95%CI = 1.7-4.0, P<0.0001, respectively). Moreover, circulating tumor DNA significantly correlated with a higher number of liver metastases, the presence of lung and/or peritoneal metastases, tumor burden, and higher carbohydrate antigen 19-9 levels. This study supports the use of circulating tumor DNA as an independent prognostic marker for advanced pancreatic cancer.

Long-term survival after repeated resection for lung metastasis originating from pancreatic cancer: a case report.

BACKGROUND: Pancreatic cancer has a grave prognosis. Most patients with metastatic pancreatic cancer are inoperable, and case reports of resection of lung metastasis from pancreatic cancer are rare. This patient underwent resection of a lung metastasis twice after pancreaticoduodenectomy for pancreatic cancer. CASE PRESENTATION: A 75-year-old man with pancreaticoduodenectomy and adjuvant chemotherapy for pancreatic cancer was diagnosed with a lung metastasis 48 months after surgery. Histological findings after thoracoscopic partial resection of the right lung by video-assisted thoracic surgery confirmed the presence of a lung metastasis originating from the pancreatic cancer. The patient refused chemotherapy. A new lung metastasis was detected 84 months following the second surgery (132 months after the pancreaticoduodenectomy). After thoracoscopic partial resection of the left lung by video-assisted thoracic surgery, the histological findings once again confirmed a metastasis that originated from the pancreatic cancer. The patient refused chemotherapy and remained alive and relapse-free after the 10-month follow-up. CONCLUSION: Detection and resection of an isolated lung metastasis originating from pancreatic cancer may improve prognosis. Careful follow-up may be warranted to identify patients who might benefit from aggressive local treatment of oligometastasic pancreatic cancer.