Small bowel bleeding treated successfully with transcatheter arterial embolization with imipenem/cilastatin.

BACKGROUND: Small bowel bleeding is an uncommon cause of lower gastrointestinal bleeding, which may require different management. CASE PRESENTATION: A 37-year-old man presenting with hematochezia was promptly diagnosed with small bowel bleeding by computed tomography angiography. Transcatheter arterial embolization was carried out because the patient's hemodynamic status deteriorated. Hemostasis was achieved by embolization with imipenem/cilastatin, although superselective embolization failed. Capsule endoscopy revealed multiple ulcers and erosions. Drug-induced small bowel injury was suspected to be the cause of small bowel bleeding. CONCLUSION: Computed tomography angiography can facilitate the management of lower gastrointestinal bleeding. Considering transcatheter arterial embolization and choosing an optimal embolic agent depending on the situation are important in the management of hemodynamically unstable patients.

Aortic Thrombosis in a Patient With Malignant Disease: A Literature Review and Case Presentation.

INTRODUCTION:: Aortic mural thrombosis associated with a malignant disease is rare, and whether anticoagulation therapy or surgical treatment is the more definitive primary treatment remains uncertain. This study aims to determine the best treatment strategy for aortic thrombosis in a patient with a malignant disease. METHODS:: We reviewed medical literature using the PubMed database and present a case of aortic thrombosis due to a hypercoagulable state related to sigmoid colon adenocarcinoma. RESULTS:: Of the 18 patients from 14 articles included in this study, 13 received simple anticoagulation as a primary treatment (anticoagulation group), while 5 underwent surgical treatment (surgical treatment group). Recurrence or exacerbation of embolism was found in 2 (15.4%) of the 13 patients and in 1 (20.0%) of the 5 patients ( P = 1.0). Major complications were observed in 1 (7.7%) of the patients in the anticoagulation group and in 1 (20.0%) of the 5 patients in the surgical treatment group ( P = .49). No significant differences between the groups were found. CONCLUSIONS:: A simple anticoagulation therapy may be as effective as surgical treatment in patients with aortic thrombosis associated with malignancy.

Laparoscopic relief of reduction en masse followed by elective preperitoneal inguinal hernia repair with Modified Kugel™ Patch.

INTRODUCTION: Reduction en masse is a rare complication of inguinal hernia. This condition is defined as the displacement of a strangulated hernia mass into the preperitoneal space. CASE PRESENTATION: A 62-year-old man presented with severe abdominal pain after a forcible reduction of an incarcerated right inguinal hernia. Abdominal computed tomography (CT) scan suggested strangulated bowel. Emergency exploratory laparoscopy was performed and the incarcerated bowel was successfully released. Elective preperitoneal inguinal hernia repair using the Modified Kugel™ Patch was performed under laparoscopic guidance. The patient made an uneventful recovery. DISCUSSION: Reduction en masse should be considered when abdominal pain persists after a difficult reduction of inguinal hernia. Laparoscopic guidance led to the definitive repair of the inguinal hernia with reduction en masse. CONCLUSION: Laparoscopic relief can be an efficient therapeutic option for the management of this condition. In addition, Modified Kugel™ Patch repair with ligation of the hernia sac could be a reasonable treatment.

A case of splenic metastasis of ovarian cancer treated with complete laparoscopic splenectomy and transvaginal specimen extraction.

A 61-year-old woman was diagnosed with right inguinal lymph node and splenic metastasis of ovarian serous cystadenocarcinoma. We performed right inguinal lymph node dissection and total laparoscopic splenectomy in the supine position followed by transvaginal specimen extraction (TVSE). First, using three ports, we extracted the right inguinal lymph node. We repaired the posterior wall of the inguinal canal using a mesh plug. We added two ports and displaced the spleen from the retroperitoneum and lifted it using a snake retractor, disconnecting the hilum using an automatic suturing device. Next, the posterior wall of the vagina was intraperitoneally incised. And an Alexis® laparoscopic system was inserted into the vagina. The cap maintained aeroperitoneum, a collection bag was inserted in the abdominal cavity via the vagina, and the spleen was collected. When the spleen was removed from the body, partial fragmentation of the organ was required in the bag. Organ fragmentation was performed only within the bag, and we made sure not to tear the bag. The vaginal wound was laparoscopically sutured. The patient had no operative complications and was able to actively ambulate at the first day after surgery due to a slight postoperative pain. Total laparoscopic splenectomy with TVSE in the supine position may be a safe and feasible method for selected female patients. This technique enables minimally invasive surgery for female patients with splenic disease.

Extraperitoneal colostomy in laparoscopic abdominoperineal resection using a hand inserted from the perineal side.

INTRODUCTION: Extraperitoneal colostomy is considered to be more effective at preventing post-colostomy complications than intraperitoneal colostomy. However, this operation is difficult via laparoscopic surgery alone. We present an extraperitoneal colostomy technique using a hand inserted from the perineal side. MATERIALS AND SURGICAL TECHNIQUE: Extraperitoneal colostomy was performed in five patients. After the rectum was resected, a hand was inserted into the abdominal cavity from the perineal side, and pneumoperitoneum was created. The peritoneum was dissected to make the extraperitoneal route, and the proximal colon was passed along this route with fingers and laparoscopic manipulation. All procedures were completed without tissue damage or hemorrhage. No patient developed a hernia or ileus postoperatively. DISCUSSION: Laparoscopic abdominoperineal resection for an extraperitoneal colostomy is difficult via laparoscopic ports only. It can be simplified by operating with manual assistance via the perineal wound.

The adenomatous polyposis coli-associated exchange factors Asef and Asef2 are required for adenoma formation in Apc(Min/+)mice.

Sporadic and familial colorectal tumours usually harbour biallelic adenomatous polyposis coli (APC)-associated mutations that result in constitutive activation of Wnt signalling. Furthermore, APC activates Asef and Asef2, which are guanine-nucleotide exchange factors specific for Rac1 and Cdc42. Here, we show that Asef and Asef2 expression is aberrantly enhanced in intestinal adenomas and tumours. We also show that deficiency of either Asef or Asef2 significantly reduces the number and size of adenomas in Apc(Min/+) mice, which are heterozygous for an APC mutation and spontaneously develop adenomas in the intestine. We observed that the APC-Asef/Asef2 complex induces c-Jun amino-terminal kinase-mediated transactivation of matrix metalloproteinase 9, and is required for the invasive activity of colorectal tumour cells. Furthermore, we show that Asef and Asef2 are required for tumour angiogenesis. These results suggest that Asef and Asef2 have a crucial role in intestinal adenoma formation and tumour progression, and might be promising molecular targets for the treatment of colorectal tumours.

Prognostic significance of BMP and activin membrane-bound inhibitor in colorectal cancer.

AIM: To investigate the clinical significance of BMP and activin membrane-bound inhibitor (BAMBI) which is a pseudoreceptor of transforming growth factor-beta (TGF-beta) type I receptors and acts as a negative regulator of TGF-beta signaling and expression aberrantly elevated in colorectal cancers (CRCs). We studied BAMBI expression in CRCs. METHODS: We studied BAMBI expression in 183 surgically resected CRCs by immunochemical and immunoblotting analyses using a generated monoclonal anti-BAMBI antibody. Commercially available anti-beta-catenin and anti-p53 antibodies were also applied for immunochemical analyses as a comparison control. RESULTS: Immunohistochemical analysis revealed that BAMBI expression was observed in 148 (80.8%), and strong BAMBI expression was observed in 46% of the CRCs. Strong BAMBI expression was positively correlated with histological type, depth of invasion, lymph node metastases, and tumor node metastasis (TNM) stage (P < 0.05). Clear associations were found between BAMBI and beta-catenin (P = 0.035) and p53 (P = 0.049) expression. In curatively resected CRC, 5-year recurrence-free survival was 51.9% (P = 0.037) for strong BAMBI expression compared to 79.8% for weak BAMBI expression. In the Cox's multivariate analysis, lymph node metastases (RR 6.685; P < 0.001) and depth of invasion (RR 14.0; P = 0.013) were significant indicators for recurrence, and strong BAMBI expression (RR 2.26; P = 0.057) tended to be significant. CONCLUSION: BAMBI was linked to a potentially aggressive tumor phenotype and predicted tumor recurrence and cancer-related death in CRC. BAMBI expression might be applicable in the routine clinical setting of CRC.

PH domain-mediated membrane targeting of Asef.

The APC-associated guanine nucleotide exchange factor (GEF) Asef regulates cell morphology and migration. Asef contains a pleckstrin homology (PH) domain in addition to Dbl homology (DH), APC-binding (ABR), and Src homology 3 (SH3) domains. Here we show that the PH domain of Asef binds to phosphatidylinositol 3,4,5-trisphophate [PtdIns(3,4,5)P3] and targets Asef to the cell-cell adhesion sites in MDCK II cells. Furthermore, we demonstrate that overexpression of Asef in MDCK II cells results in increases in the amounts of E-cadherin and the actin filaments at the sites of cell-cell contact. These results suggest that Asef is targeted via its PH domain to the cell-cell adhesion sites and is involved in the regulation of cell adhesion.