Preoperative Diagnosis and Treatment of Cholecystoduodenal Fistula.

The case is about an 87-year-old female. While staying at a facility, she had a fever and abdominal pain and visited our hospital for an up-close examination and treatment. An abdominal CT scan revealed gallstones, gallbladder enlargement, and common bile duct stones. Endoscopic retrograde cholangiopancreatography was performed to confirm the presence of common bile duct stones, which were extracted. At that time, she was diagnosed with a duodenal fistula of the gallbladder and underwent surgery in our department. The gallbladder and duodenum were firmly adhered, and gallstones were palpated between the gallbladder and duodenum. The gallbladder was incised at the fundus to check the lumen, and gallstones were lodged in the fistula with the duodenum. After the removal of gallstones, the gallbladder was dissected, and a fistula with the duodenum was identified. After treating the cystic duct, the fistula was removed, and the gallbladder was removed. Because the duodenal wall was fragile due to inflammation and the fistula was large and difficult to close simply, the duodenal bulb was separated with a linear stapler, and the stomach and jejunum were reconstructed with a 25-mm CDH using the Roux-en-Y technique. The patient's postoperative course was good, and she was discharged from the hospital.

Intraductal Papillary Mucinous Neoplasm of the Pancreas Associated with Polycystic Liver and Kidney Disease.

A 77-year-old man was pointed out thrombocytopenia and polycystic liver and kidney disease following hypertension and diabetes mellitus and duodenitis. He consulted to our hospital for further examination. Computed tomography (CT) showed multiple cysts in the liver and kidney and also showed cystic lesions in the pancreatic tail. The size of the tumor of pancreas was 3 cm × 4 cm. FDG-PET CT showed FDG uptake in the tumor of the pancreatic tail. It has not showed metastasis in the other organs. The examinations suggested that the cause of thrombocytopenia was infection of Helicobacter pylori or idiopathic thrombocytopenic purpura or drugs. We performed distal pancreatectomy for the tumor of pancreas. Histological findings revealed that the tumor of pancreas was invasive intraductal mucinous carcinoma. He had no recurrence for 3 months after operation. In this case, the patient with autosomal-dominant polycystic kidney disease (ADPKD) and multiple liver cysts developed IPMC. We suggest that some genetic interactions may exist between ADPKD and pancreatic carcinogenesis.

[Two Patients with Recurrence of Hepatocellular Carcinoma after Liver Resection Who Achieved Long-Term Stable Disease with Small Doses of Sorafenib Therapy].

Case 1: A6 4-year-old man with hepatocellular carcinoma (HCC) had received local therapy repeatedly for 20 years. In 2012, he underwent hepatic right lobectomy for recurrence of HCC. Multiple recurrences were found in the hepatic remnant, and transcatheter arterial chemoembolization (TACE) was performed. Considering his condition, a small dose of sorafenib (200 mg per day) was administered. He complained of general fatigue, so we prolonged the administration interval (200 mg every other day). Thereafter, compliance improved and long-term stable disease (long SD), for more than 6 months, long SD was achieved. Case 2: A7 5-year-old man with HCC was treated by TACE repeatedly for multiple recurrences after liver resection (segment 6). In 2008, metastases to the thoracic vertebra and left rib were treated by radiation therapy and radiofrequency ablation, respectively. Subsequently, sorafenib (400 mg per day) was administered. We reduced the dose of sorafenib to less than 400 mg per day because of diarrhea, hypertension, and general fatigue. Thereafter, long SD was achieved despite the small dose of sorafenib. We report here 2 cases of HCC where we achieved long SD in spite of treating with a small dose of sorafenib.

Cystic lymphangioma of the chest wall: a case report.

Cystic lymphangioma is a congenital cystic malformation that occurs mostly in children. While it is mainly found in the cervix, cases in the chest wall are very rare. We report a case of cystic lymphangioma found in the chest wall of a 2-month-old girl. The patient was noted to have a tumor in the left chest wall at birth. Since it gradually increased in size, the patient was referred to our department. Transillumination and ultrasonography showed a cystic lesion in the left chest. Surgical resection was performed in one step. Histopathological examination showed a cystic lymphangioma.

Successful surgical control of peritoneal dissemination of hepatocellular carcinoma.

Treatment for the peritoneal dissemination of hepatocellular carcinoma (HCC) has not yet been established. We report a patient with HCC associated with disseminated intra-abdominal tumor. A 74-year-old man was admitted to our hospital. Computed tomography showed a 3 × 3 cm mass in the left hepatic lobe and a giant mass between the stomach and spleen. At laparotomy, the tumor was seen in the medial segment and evaginated to the diaphragm. There was a tumor between the stomach and spleen, confirmed as a 5 × 5 cm tumor evaginated from the left diaphragm, and a 7 × 7 cm tumor adhesive to the spleen. These two tumors were not continuous and were separated. Furthermore, we confirmed a 10 × 10 cm tumor in the pelvic cavity. We performed partial hepatectomy, resection of the tumor evaginated from the diaphragm, resection of the tumor of the spleen and tail of pancreas, and resection of the tumor in the pelvic cavity. Histopathologically, all resected tumors were confirmed to be well-differentiated HCC. HCC rarely disseminates intraperitoneally. It is considered that the peritoneal dissemination of HCC occurred from poorly differentiated or undifferentiated type. Then this report is a rare case. Although surgical treatment of peritoneal dissemination of HCC is not curative, surgery may improve survival and provide good quality of life in selected cases.

Surgical Control of a Primary Hepatic Carcinoid Tumor: A Case Report.

We report a primary hepatic carcinoid tumor occurring in a 47-year-old man. The patient consulted our hospital complaining of epigastralgia. Abdominal ultrasonography, computed tomography scanning, and magnetic resonance imaging showed a large mass in the right lobe of the liver. FDG-PET revealed 18F-FDG uptake by the right hepatic lobe. The tumor was a solid mass with cystic components, approximately 15 cm in diameter. We conducted an extended right lobectomy of the liver. The resected specimen was a solid tumor with cystic components and hemorrhagic lesion. Microscopic findings showed that the tumor cells had round nuclei and formed trabecular patterns. Immunohistologically, tumor cells were stained positive for chromogranin A, neuron specific enolase, CD56, and S-100. Careful examinations before and after the operation revealed no other possible origin of the tumor. Based on these findings, the tumor was diagnosed as a primary hepatic carcinoid. This is a report of a rare case of a primary hepatic carcinoid tumor with a discussion of several other relevant reports.

Overproduction of PGE2 in peripheral blood monocytes of gastrointestinal cancer patients with mucins in their bloodstream.

When monocytes from healthy donors were cultured in the presence of sera from patients with gastrointestinal cancer, PGE2 production from the monocytes was elevated. Serum proteins were fractionated on Sepharose 4B and the inducing activity was found in the excluded fractions. By excluding some mucins from the serum, the inducing activity was reduced effectively. The activity was also reduced by adding binding inhibitors to the scavenger receptor. These results suggest that peripheral blood monocytes in epithelial cancer patients may be continuously stimulated by mucins in the bloodstream through the scavenger receptor, resulting in overproduction of PGE2.

Enhanced production of interleukin 6 in peripheral blood monocytes stimulated with mucins secreted into the bloodstream.

PURPOSE: It has been reported that tumor progression is correlated with the serum level of interleukin 6 (IL-6). The purpose of this study was to investigate by what mechanism, other than production from tumor cell, the serum level of IL-6 is elevated in the tumor-bearing state. EXPERIMENTAL DESIGN: Monocytes from healthy donors were cultured in the presence of sera from colon cancer patients, and the activity to elevate IL-6 production was estimated. This activity of serum was also examined after various biochemical treatments. RESULTS: When monocytes from healthy donors were cultured in the presence of sera from patients with colon cancer, secretion of IL-6 from the cells was markedly elevated. Serum proteins were fractionated on Sepharose 4B and the activity to elevate IL-6 production was found in the excluded fractions. Sialyl Tn antigen was detected in these same fractions. By excluding some mucins from the serum, the inducing activity was reduced to 40% of the original level. Furthermore, we purified mucins from the conditioned medium of colon cancer cells. Production of IL-6 was effectively elevated by a small amount of purified mucins in a dose-dependent manner. When the inducing activity was examined in the presence of binding or competitive inhibitors to the scavenger receptor, the effect was remarkably reduced. CONCLUSIONS: Mucins secreted from colon cancer cells into the bloodstream induce production of IL-6 in peripheral blood monocytes through the scavenger receptor, which may be responsible for the high level of serum IL-6 in colon cancer patients.

Living donor liver transplantation in a recipient with anti-Fy(a) and Jk(a) antibodies.

We report a case of a living donor liver transplantation using right lobe graft to a recipient having anti-Fy(a) and Jk(a) antibodies. The red blood cell (RBC) antigens of the donor were Fy (a+) and Jk (a-). We attempted to eliminate donor RBCs remaining in the graft by perfusing histidine-tryptophan-ketoglutarate. Further, Fy (a-)/Jk (a-) RBC concentrates were transfused during the operation. However, the anti-Fy(a) titer increased approximately 8-fold on the seventh postoperative day. On the same day, serum levels of transaminase and total bilirubin increased presumably due to acute cellular rejection. Steroid administration immediately reduced levels of transaminase, total bilirubin and anti-Fy(a) titer. The increase of anti-Fy(a) titer may be due to a secondary immune response to the donor's Fy(a) antigen on RBCs remaining in the graft.

Positive status of alpha-fetoprotein and des-gamma-carboxy prothrombin: important prognostic factor for recurrent hepatocellular carcinoma.

The aim of this study was to evaluate prognostic factors after the recurrence of hepatocellular carcinoma (HCC) in patients who had undergone hepatic resection. We used univariate and multivariate retrospective analyses of 29 clinicopathologic factors in 143 patients with recurrent HCC. Patients were classified into four groups according to the positivity of tumor markers at the time of recurrence. Survival rates and prognostic factors were then compared among the four groups. Multivariate analysis revealed four independent prognostic factors at recurrence: albumin level < 3.5 g/dl ( p = 0.0003), period until recurrence

Pirfenidone prevents endotoxin-induced liver injury after partial hepatectomy in rats.

BACKGROUND/AIMS: Massive liver resection causes a variety of complications including endotoxemia. Pirfenidone (PFD) is a new experimental drug used as antifibrotic agent. Studies were performed to investigate whether PFD influences the survival rate of animals with endotoxin-induced liver injury after partial hepatectomy, and the mechanisms involved. METHODS: Rats were treated with lipopolysaccharide (LPS) 48 h after 70% hepatectomy. PFD was administered orally before LPS injection. RESULTS: PFD improved the survival rate of LPS-treated rats after hepatectomy. PFD prevented increases in serum enzymes and total bilirubin related to liver injury. Histopathological analysis revealed that PFD inhibited the enhancement in hepatic necrosis and apoptosis. Further, PFD inhibited increases of inflammatory cytokines and cytokine-induced neutrophil chemoattractant (CINC) in serum and liver, followed by decreases of number of infiltrating neutrophils into liver. Electrophoretic mobility shift assay revealed that PFD inhibited the activation of transcription factor nuclear factor-kappa B (NF-kappa B) induced by LPS. PFD also reduced the induction of inducible nitric oxide synthase (iNOS) in the liver of LPS-treated rats. CONCLUSIONS: These results indicate that PFD inhibits the productions of inflammatory cytokines, CINC and iNOS in part through the inhibition of NF-kappa B activation, resulting in the prevention of endotoxin-induced liver injury after hepatectomy.

Intrahepatic sarcomatoid cholangiocarcinoma.

A 69-year-old woman was admitted to our hospital with fever and abdominal pain in the epigastric region. Abdominal ultrasonography demonstrated a well-defined hypoechoic mass in the epigastric region with encasement of the left hepatic lobe and stomach. Computed tomography confirmed a low-density mass, 20 cm in diameter, with enhancing peripheral areas. Angiography revealed the tumor to be hypovascular. After admission, the patient had a persistent fever and anemia that required transfusions of concentrated red blood cells. On the twelfth day after admission, she suffered disseminated intravascular coagulation and underwent an emergency operation. A lateral segmentectomy with dissection of lymph nodes, cholecystectomy, and hemigastrectomy were carried out. The size of the tumor was 22 x 17 x 15 cm. Macroscopically, a cross-section revealed massive necrosis with hemorrhage. Histological examination of the tumor showed a malignant neoplasm with a carcinomatous component and a sarcomatous component, which were partly intermingled. The former consisted of moderately differentiated adenocarcinoma, while the latter consisted of pleomorphic spindle cells. Immunohistochemical examination of the sarcomatous component showed positive staining for vimentin, epithelial membrane antigen, and cytokeratin. The tumor was diagnosed as cholangiocarcinoma with extensive sarcomatous changes, based on these histological and immunohistochemical findings. The patient had an uneventful postoperative course. However, she died 3 months after surgery from dissemination of the carcinoma. The literature on this rare disease is reviewed and discussed.

Refractoriness to platelet transfusion following partial hepatectomy for hepatocellular carcinoma: report of two cases.

Refractoriness to platelet transfusion indicates a condition in which an expected increase in platelet count is not attained after platelet transfusion. We report herein two cases of refractoriness to platelet transfusion that were caused by the presence of antibodies against the human leukocyte antigen following partial hepatectomy for hepatocellular carcinoma. Due to low postoperative platelet counts in the first case, the patient was transfused with 75 units of platelet concentrate for 3 days after surgery, but was unable to gain a significant increase in the platelet count because of platelet transfusion refractoriness due to anti-human leukocyte antigen antibodies. This case was not complicated and had a favorable clinical course. Despite being transfused with 60 units of platelet concentrate during the 2 days after surgery, the patient's platelet count in the second case did not increase because of the presence of anti-human leukocyte antigen antibodies. Bleeding from the cut surface of the liver into the intraperitoneal cavity was found on the second postoperative day because of a decrease in platelet count. On postoperative day 5, disseminated intravascular coagulation occurred. Perioperative refractoriness to platelet transfusion is an intractable complication since no efficient treatment is available. Preoperative examinations for anti-platelet antibodies should be performed in patients undergoing hepatectomy for hepatocellular carcinoma. This is especially true in cases of decreased platelet counts due to preceding liver cirrhosis and when the prediction for postoperative platelet transfusions is necessary.