Cholangiocarcinoma in a middle-aged patient working at a printing plant.

A 39-year-old male with elevated serum transferases consulted our hospital in September 2010. Since 1999, he had worked at a printing company using organic solvents. Cholangiography revealed stenosis of the left hepatic duct with peripheral dilation, stricture of the right hepatic duct, and irregularity of the extrahepatic bile duct. As a preoperative diagnosis of sclerosing cholangitis and cholangiocarcinoma was made, extended left hepatectomy with resection of the extrahepatic bile duct and anastomosis of the anterior and posterior branches of the bile duct and the jejunum (Roux-en Y reconstruction) were performed. A histological examination showed papillary carcinoma of the medial hepatic bile duct with intraductal growth, and biliary intraepithelial neoplasia-2/3 lesions from the medial hepatic bile duct to the right hepatic and the common bile ducts. Chronic cholangitis was shown around the tumors. Postoperatively, the patient was treated with adjuvant chemo-radiation, and he is doing well 30 months after the operation, without recurrence. Unknown causes, including exposure to organic solvents, might have induced chronic bile duct injury and contributed to the development of cholangiocarcinoma.

Management of postoperative intraabdominal abscess in laparoscopic versus open appendectomy.

BACKGROUND: Complicated appendicitis (gangrenous or perforated appendicitis) is a risk for postoperative intraabdominal abscess, but management of intraabdominal abscess may differ between laparoscopic and open appendectomy. METHODS: We reviewed 67 patients who underwent appendectomy for complicated appendicitis, including 26 who received laparoscopic appendectomy (LA group) and 41 who underwent open appendectomy (OA group). The operation was performed under general anesthesia in all 26 patients in the LA group and in 10 (24%) in the OA group. Patient characteristics, operative factors, and postoperative complications (especially postoperative intraabdominal abscess) were compared between the two groups. Management of postoperative intraabdominal abscess was also investigated. RESULTS: Postoperative intraabdominal abscess occurred in 3 patients (12%) in the LA group and in 10 (24%) in the OA group (p = 0.23). All 3 patients in the LA group were treated conservatively. Of the 10 patients in the OA group, 6 were treated conservatively, but 4 needed a reoperation, including 3 who had undergone right pararectal skin incision under spinal analgesia and in whom sufficient irrigation was not possible because anesthesia had worn off. CONCLUSIONS: Our results suggest that insertion of abdominal drainage may be appropriate treatment for intraabdominal abscess after laparoscopic appendectomy. Light anesthesia may induce residual abscess in open appendectomy performed under spinal analgesia.

Colorectal cancer metastasis to the thyroid.

A 69-year-old Japanese woman underwent a curative operation for rectal cancer (T2, N0, M0, Dukes B, R0, and stage IIA of American Joint Committee on Cancer) 3 years ago. On subsequent routine follow-up, a right-side thyroid nodule and a regional lymph node of up to 1.5 cm in diameter was palpated. FDG-PET demonstrated high FDG accumulation in the right lobe of the thyroid gland, neck lymph nodes, and sacral periosteum. We diagnosed a local recurrence of rectal cancer and a primary thyroid cancer. We chose radiotherapy for the periosteal recurrence, and then right hemithyroidectomy with regional lymph node dissection for the thyroid tumor was performed. Pathological examination demonstrated mucinous carcinoma, the same as the previous surgical specimen from the rectum. She had been treated with postoperative chemotherapy and had been alive and well for 26 months with lung metastases. Although thyroid gland metastasis from colorectal cancer is rarely reported, physicians should consider the possibility of thyroid gland metastasis when performing routine follow-up examinations for recurrence of colorectal cancer.

Hepatectomy for hepatocellular carcinoma in patients with severe thrombocytopenia.

BACKGROUND/AIMS: Hepatic resection for hepatocellular carcinoma (HCC) is risky for cirrhotic patients with severe thrombocytopenia. METHODOLOGY: Among 23 patients with histologically proven cirrhosis who underwent hepatic resection for HCC at our hospital since 2006, 7 had severe thrombocytopenia (platelet count <5×104/mm3). The clinical background and surgical outcomes of these 7 patients were retrospectively evaluated and compared to those of the 16 cirrhotic patients without severe thrombocytopenia. RESULTS: All 7 patients had hepatitis C virus-related liver cirrhosis. The median preoperative platelet count was 4.3×104/mm3 (range, 3.9-4.9×104/mm3) and the median operative time and intraoperative bleeding were 77min and 193cc, respectively. Postoperative complications were observed in 4 patients (57%) and all were managed conservatively. Four patients received an intraoperative platelet-rich transfusion, but this had no beneficial effect on intraoperative bleeding or postoperative changes in platelet counts. The cirrhotic patients with severe thrombocytopenia were significantly younger and had a significantly shorter operative time compared to those without severe thrombocytopenia. There were no other differences between the groups. CONCLUSIONS: Our results suggest that the indication for hepatectomy in cirrhotic patients should not be based on platelet counts alone. However, we note that the younger age and shorter operative time for the patients with severe thrombocytopenia might have contributed to the safety of hepatectomy.

Tumor Implantation into the Intrahepatic Bile Duct after Percutaneous Ethanol Injection Therapy for Hepatocellular Carcinoma.

A 74-year-old man who had undergone transcatheter arterial embolization for hepatitis C virus-related hepatocellular carcinoma (Couinaud's segment III/IV) in April 2003 and percutaneous ethanol injection for recurrence at the same site in February 2006 was found to have dilation of the intrahepatic bile duct by computed tomography in October 2008. Contrast-enhanced computed tomography and magnetic resonance cholangiopancreatography showed a thrombosis occupying the left hepatic duct to the lateral branches with peripheral bile duct dilation. Serum concentration of alpha-fetoprotein was elevated. We performed a left hepatectomy under a preoperative diagnosis of hepatocellular carcinoma with bile duct invasion. The cut surface of the resected specimen showed a tumor thrombosis occupying the region between the left hepatic duct and lateral branches, but no tumor in the liver parenchyma. Histologic examination showed that the thrombosis in the intrahepatic bile duct was hepatocellular carcinoma. Since part of the hepatocellular carcinoma in the region treated with percutaneous ethanol injection was adjacent to the tumor thrombosis in the intrahepatic bile duct in diagnostic imaging, we diagnosed implantation into the intrahepatic bile duct due to percutaneous ethanol injection. The postoperative course was uneventful and the patient is doing well without recurrence 8 months after the operation.