Aggressive behavior of anaplastic undifferentiated carcinoma arising from the hilar bile duct

Background

Undifferentiated carcinoma of the biliary tree is extremely rare, and biliary undifferentiated carcinoma mostly originates from the gallbladder. We herein present a case of anaplastic undifferentiated carcinoma of the hilar bile duct and reviewed the literature.

Case presentation

The patient was an 81-year-old male with obstructive jaundice. Contrast-enhanced computed tomography (CT) showed a protruded tumor located at the hepatic hilum. Obstructive jaundice was relieved by endoscopic drainage. Endoscopic biopsy revealed carcinoma without glandular differentiation, and the patient was diagnosed with resectable hilar undifferentiated carcinoma. During the 5-week preoperative examination, the tumor increased in size from 23 to 45 mm. Left hemi-hepatectomy and extrahepatic bile duct resection were performed, and there were no postoperative complications. Histological findings demonstrated that the tumor was mainly composed of non-cohesive polygonal neoplasms with pleomorphic nuclei, and was diagnosed as anaplastic undifferentiated carcinoma of the common hepatic duct (T2a N0 M0 Stage II). One month after surgery, the patient was readmitted to our hospital with pyrexia due to cholangitis, and liver nodules suggestive of multiple liver metastases were detected by CT. Three months after surgery, the patient died of multiple liver metastases.

Conclusions

This is the first case report of undifferentiated cholangiocarcinoma with anaplastic features. Anaplastic undifferentiated carcinoma of the hilar bile duct showed preoperative rapid growth and early relapse despite a cancer-negative surgical margin.

Anatomical change of SMV branches after the Cattell Braasch maneuver facilitates safe resection around the uncinated process in pancreatoduodenectomy

Background

The aims of the present study were to demonstrate the anatomical change of superior mesenteric vein (SMV) branches and to show how the Cattell Braasch maneuver facilitates a safer ligation of these venous branches during a pancreatoduodenectomy (PD).

Methods

Between January 2010 and December 2019, 97 patients with peripancreatic tumors underwent pancreatectomy. We retrospectively reviewed preoperative triple-phase enhanced computed tomography (CT) images and analyzed variations in SMV branches. Anatomical changes in SMV branches after the Cattell Braasch technique were observed using our operation video and illustrations.

Results

The first jejunal vein (J1v) in 75% of patients ran posterior to the superior mesenteric artery (SMA), while the remainder (25%) ran anterior to it. The inferior pancreatoduodenal vein (IPDV) was preoperatively detected in 91% of patients. The IPDV drained into the J1v in 74% of patients and into the SMV in 37%. After the Cattell Braasch maneuver, the J1v which ran posterior to the SMA now was found to lie to the right anterolateral side the SMA and the visualization of both the J1v and the IPDV were much more clearly visualized.

Conclusions

The most frequent venous variation was the IPDV draining into the J1v posterior to the SMA. After the Cattell Braasch maneuver, the IPDV was now located to the right anterolateral anterior aspect of the SMA which facilitates its visualization and should allow a safer ligation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01338-5.

A case report of a gastrobronchial fistula and lung abscess caused by leakage from the staple line of a gastric tube after esophagectomy for esophageal cancer

BACKGROUND

Gastrobronchial fistulas are rare, but life-threatening, complications of esophagectomy. They are caused by anastomotic leakage and mainly occur around anastomotic sites. In the present paper, we report a rare case of leakage from the staple line of a gastric tube after esophagectomy for esophageal cancer, which was successfully treated using an intercostal muscle flap and lung resection.

CASE PRESENTATION

A 61-year-old male underwent subtotal esophagectomy with regional lymphadenectomy for esophageal cancer. The sutures along the staple line of the gastric tube failed 11 days after surgery, and a pulmonary abscess was also found on imaging. The abscess did not heal after conservative treatment; therefore, right lower lobectomy, gastrobronchial fistula resection, primary closure, and patching of the leaking portion of the gastric tube with an intercostal muscle flap were performed 9 months after the first operation. The patient's postoperative course was uneventful, and he was discharged on the 354th day.

CONCLUSIONS

We experienced a case involving a gastrobronchial fistula caused by leakage from the staple line of a gastric tube and successfully treated it by performing right lower lobectomy and patching the leak with an intercostal muscle flap.

Morphological plaque characteristics and clinical outcomes of acute coronary syndrome patients with a cancer history

Background

Although previous studies have reported that patients with a history of cancer have 2–3 times higher risks for acute coronary syndrome (ACS), morphological culprit plaque characteristics in ACS patients with a cancer history and their relations with clinical outcomes remain unknown.

Methods

The Kobe University ACS-OCT registry is a multi-center registry of consecutive ACS patients who underwent OCT-guided emergent PCI in Japanese four centers. All patients were categorized into the patients without a history of cancer (non-cancer), those with a history of cancer who diagnosed more than one year before ACS (historical), and those with ongoing cancer treatment or diagnosis within one year before ACS (current). ACS culprit lesions were classified into plaque rupture (PR), plaque erosion (PE), and calcified nodule (CN) according to morphological features by OCT and clinical events were collected after the onset of ACS.

Results

Among 436 patients, 63 patients (14.4%) had a history of cancer or ongoing treatment of cancer (cancer patients). Cancer patients were significantly older than non-cancer patients (73.4±9.4 vs. 66.9±12.9, p=0.001), and non-ST segment elevation ACS was more frequently observed in cancer patients than in non-cancer patients (57.1% vs. 43.2%, p=0.039). Regarding the ACS culprit lesion, the frequency of PR was significantly lower and the frequencies of PE and CN were significantly higher in the cancer patients than in the non-cancer patients (Figure A1). The cumulative incidence of major adverse cardiovascular event (MACE: composite of cardiac death, non-fatal myocardial infarction, and any revascularization, stroke, and heart failure with admission) after the onset of ACS in cancer patients was significantly higher than that in the non-cancer patients (Figure B1). When the cancer patients were categorized into the historical and the current cancer patients, the frequency of PE was higher in the current and the historical cancer patients than the non-cancer patients. Also, the incidence of CN was significantly higher in the historical cancer patients than others (Figure A2). The cumulative incidence of MACE was significantly higher in the current cancer patients, followed by historical and non-cancer patients (Figure B2). Cox regression analyses demonstrated that the non-PR lesion (hazard ratio (HR) 0.65, 0.46–0.94, p=0.021), patients with multivessel disease (HR 2.55, 1.79–3.64, p<0.001), older patients (HR 1.02, 1.00–1.03, p=0.043) were independently associated with MACE after ACS. Moreover, multivariate analysis demonstrated that cancer history (HR 4.64, 2.34–9.21, p<0.001) and non-ST segment elevation ACS (HR 0.66, 2.34–9.21, p=0.038) were independently associated with non-PR lesion.

Conclusions

The present study revealed the difference in morphological plaque characteristics between cancer and non-cancer patients, which might explain potential underlying mechanisms for worse outcomes in cancer patients.

Funding Acknowledgement

Type of funding source: None

Bochdalek hernia in an adult: two case reports and a review of perioperative cardiopulmonary complications

Background

Bochdalek hernia in an adult is very rare and often needs an immediate surgical repair for the herniation. Although its etiology and surgical techniques have frequently been reported, perioperative complications, especially cardiopulmonary problems, remain unknown. We reported two adults with Bochdalek hernia and reviewed the published literatures with a focus on these issues.

Case presentation

We experienced two adult cases of Bochdalek hernia with gastrointestinal strangulation. One case had massive herniation of the stomach, colon, spleen, and pancreas in the left chest, causing repeated vomiting. The other had a right-side hernia with strangulation of the colon. We successfully performed emergency repairs of these diaphragmatic hernias without any postoperative complications.

Conclusions

Our literature review revealed that life-threatening cardiopulmonary complications, such as empyema or cardiac arrest caused by the tamponade effect of the herniated viscera, sometimes occurred in patients with Bochdalek hernia. These complications were found in Bochdalek hernia with gastrointestinal strangulation.

105Calcified nodule in coronary artery: clinical features and prognosis with optical coherence tomography-guided percutaneous coronary intervention

Background

Calcified nodule (CN) in coronary artery is known to be a significant factor for stent underexpansion, however, its baseline characteristics and long-term prognosis is unclear.

Method

421 consecutive severe calcified lesions (Defined as maximum calcium arc >180 degrees) which underwent optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) were analyzed between January 2013 and December 2017. We investigated baseline characteristics and OCT parameter (maximum arc of calcium, maximum thickness of calcium, and length of calcium) and long-term clinical outcome (Major adverse cardiac event (MACE), any cause of death, acute myocardial infarction (AMI) and target vessel failure (TVF)). Median follow up period was 33.7 months.

Result

CN was seen in 22.3% (94 lesions) of all severe calcified lesions. Baseline characteristics and OCT parameters were significantly different in CN and non-CN groups (Hemodialysis; 23.6% vs. 14.1%, p=0.03, Multivessel Disease; 57.4% vs. 44.6, p=0.03, maximum arc of calcium; 305.4 vs. 286.1, p=0.02, maximum thickness of calcium (μm); 1206.2 vs 1123.8, p=0.01, length of calcium (mm); 24.6 vs. 19.0, p=0.01). CN lesions was strongly associated poor long-term clinical outcome (MACE; 50.5% vs. 25.7%, p<0.01), any cause of death; 18.1% vs. 9.5%, p=0.02, AMI; 7.4% vs. 2.4%, p=0.02, TVF; 38.3% vs. 19.2%, p<0.01).

Conclusion

Hemodialysis, multivessel disease and abundant calcium component may have accompanied with CN which may result in poor long-term prognosis.

P3577Predictors analysis of restenosis in calcified nodule with OCT-guided PCI

Background

Recent reports show that stenting for coronary calcified nodule (CN) resulted in frequent in-stent restenosis, however, its predictors are unclear.

Method

117 consecutive calcified nodule lesions which underwent optical coherence tomography (OCT)-guided PCI were analyzed between January 2013 and March 2018. We investigated baseline characteristics and OCT parameter in CN site (Arc of CN, Lumen area and Symmetry index before and after PCI).

Result

CN site in-stent restenosis was seen 35 lesions (29.9%). Baseline characteristics was significantly different between restenosis group and non-restenosis group (Age; 68.9y.o vs. 73.3y.o, p=0.01, diabetes mellitus; 80.0% vs. 57.3%, Chronic Kidney Disease (CKD); 74.3% vs. 36.6%, Hemodialysis; 54.3% vs. 12.2%). Arc of CN before PCI in restenosis group was larger than that in non-restenosis group (122.7 vs. 110.0 degrees, p=0.01). Post stent symmetry index in restenosis group was smaller than that in non-restenosis group (0.64 vs. 0.75, p<0.01).

Conclusion

Younger patients, diabetes mellitus, CKD, hemodialysis, arc of CN before PCI, post stent symmetry index may be predictors of CN site restenosis.

Review of the literature laparoscopic surgery for metastatic hepatic leiomyosarcoma associated with smooth muscle tumor of uncertain malignant potential: Case report

Metastatic hepatic leiomyosarcoma is a rare malignant smooth muscle tumor. We report a case of metastatic hepatic leiomyosarcoma associated with smooth muscle tumor of uncertain malignant potential (STUMP). A 68-year-old female presented with a liver mass (60 mm × 40 mm, Segment 4). She underwent left salpingo-oophorectomy for an ovary tumor with STUMP in a broad ligament 6 years ago. Though FDG-PET showed obvious metabolically active foci, abnormal metabolically active foci other than the lesion were not detected. A malignant liver tumor was strongly suspected and laparoscopic partial liver resection was performed with vessel-sealing devices using the crush clamping method and Pringle maneuver. Immunohistochemical findings revealed metastatic liver leiomyosarcoma associated with STUMP in a broad ligament. This case is an extremely rare case of malignant transformation from primary STUMP to metastatic hepatic leiomyosarcoma. It provides important evidence regarding the treatment for metastatic hepatic leiomyosarcoma associated with STUMP.

Adenomyomatosis Concomitant with Primary Gallbladder Carcinoma

Some clinicians have proposed a relationship between gallbladder (GB) cancer and adenomyomatosis (ADM) of the gallbladder, although the latter condition is not considered to have malignant potential. We retrospectively reviewed the surgical pathology database of patients who underwent resection for ADM of the gallbladder at our institution from March 2005 to May 2015. In total, 624 patients underwent surgical resection of the gallbladder with Rokitansky-Aschoff sinuses. Of these cases, 93 were pathologically diagnosed with ADM of the gallbladder, with 44 (47.3%) classified macroscopically as fundal-type ADM, 26 (28.0%) as segmental type, and 23 (24.7%) as diffuse-type ADM. In 3 of the 93 (3.2%) resected specimens, early-stage GB carcinoma was detected, although preoperative imaging did not suggest a malignant neoplasm of the gallbladder in any of these patients. GB cancer subsequently developed in the mucosa of the fundal compartment distal to the annular stricture of the segmental-type ADM in 2 of these patients and against the background of the fundal-type ADM in 1 patient. This study revealed the difficulty of early diagnosis of primary GB cancer in the setting of concurrent ADM, and clinicians should be aware of this frequent coexistence.

Surgical Management in Patients with Gastrointestinal Stromal Tumors: A Single-Center Experience

BACKGROUND

We have revisited prognostic outcomes and recurrence patterns in patients with gastrointestinal stromal tumors (GISTs) who underwent complete surgical resection at a single institution.

PATIENTS AND METHODS

Patients who underwent curative surgical treatment were divided into two groups: those with high-risk GISTs (high-risk group) and those with very low-, low-, and intermediate-risk GISTs (lower-risk group).

RESULTS

A total of 109 patients who underwent surgery as an initial treatment for GIST were studied. The overall 5- and 10-year survival rates after surgery were 90.3 and 71.1%, respectively. The 5-year survival rate in high-risk group patients was 88.1%, and their overall survival rate did not vary significantly from that of the lower-risk group (5-year survival rate, 91.3%). The recurrence rate in patients with high-risk GISTs gradually increased without reaching a plateau, with a cumulative rate of GIST recurrence of 26.4 and 48.9% at 5 and 10 years after surgical treatment, respectively.

CONCLUSIONS

Our data suggest that the repeat surgical management in metastatic GIST is of clinical usefulness whatever the risk and improves survival.

Liver function assessment using 99mTc-GSA single-photon emission computed tomography (SPECT)/CT fusion imaging in hilar bile duct cancer: A retrospective study

BACKGROUND

The objective of this study was to determine the utility of Tc-99m-diethylenetriamine-penta-acetic acid-galactosyl human serum albumin ((99m)Tc-GSA) single-photon emission computed tomography (SPECT)/CT fusion imaging for posthepatectomy remnant liver function assessment in hilar bile duct cancer patients.

METHODS

Thirty hilar bile duct cancer patients who underwent major hepatectomy with extrahepatic bile duct resection were retrospectively analyzed. Indocyanine green plasma clearance rate (KICG) value and estimated KICG by (99m)Tc-GSA scintigraphy (KGSA) and volumetric and functional rates of future remnant liver by (99m)Tc-GSA SPECT/CT fusion imaging were used to evaluate preoperative whole liver function and posthepatectomy remnant liver function, respectively. Remnant (rem) KICG (= KICG × volumetric rate) and remKGSA (= KGSA × functional rate) were used to predict future remnant liver function; major hepatectomy was considered unsafe for values <0.05. The correlation of remKICG and remKGSA with posthepatectomy mortality and morbidity was determined.

RESULTS

Although remKICG and remKGSA were not significantly different (median value: 0.071 vs 0.075), functional rates of future remnant liver were significantly higher than volumetric rates (median: 0.54 vs 0.46; P < .001). Hepatectomy was considered unsafe in 17% and 0% of patients using remKICG and remKGSA, respectively. Postoperative liver failure and mortality did not occur in the patients for whom hepatectomy was considered unsafe based on remKICG. remKGSA showed a stronger correlation with postoperative prothrombin time activity than remKICG.

CONCLUSION

(99m)Tc-GSA SPECT/CT fusion imaging enables accurate assessment of future remnant liver function and suitability for hepatectomy in hilar bile duct cancer patients.

Epiploic gonadal vein as a new bypass route for extrahepatic portal venous obstruction: report of a case

A 61-year-old man was referred to our hospital to treat extrahepatic portal venous obstruction. Endoscopic injection sclerotherapy (EIS) was performed for the esophageal varices; however, the patient returned with massive hematemesis from gastric varices 6 months after treatment. Although the varices were treated with EIS, gastric devascularization and splenectomy concomitant with shunt surgery were required to treat uncontrollable, frequent diarrhea and abdominal distension. Because the splenic vein, left gastric vein, left portal vein, and inferior vena cava were inadequate for anastomosis, an epiploic gonadal vein bypass was performed. The bypass graft remains patent 7 months after surgery, and the patient is in good health without any clinical symptoms. We describe a new bypass route for extrahepatic portal venous obstruction.

Reconsideration about the aggressive surgery for resectable pancreatic cancer: a focus on real pathological portosplenomesenteric venous invasion

BACKGROUND

Some clinicians have argued that combining pancreatic and portomesenteric venous resection could improve the rates of long-term survival. However, whether resection of the portosplenomesenteric vein could provide an acceptable survival benefit to patients with pancreatic cancer involving the portosplenomesenteric system remains controversial. The purpose of this study was to determine the significance of pathological portosplenomesenteric venous invasion on survival in patients who underwent surgical management for pancreatic adenocarcinoma.

METHODS

Patients who underwent curative surgical treatment were divided into two subgroups: those with pathological invasion to the portosplenomesenteric vein (PV-positive group) and those without invasion (PV-negative group).

RESULTS

Of 160 studied patients, the median overall survival was 48.0 months after pancreatic surgery in the PV-negative group and 18.0 months in the PV-positive group. The incidence of postoperative peritoneal dissemination was significantly lower in the PV-negative group than in the PV-positive group. Accordingly, patients in the PV-negative group showed a cumulative rate of pancreatic cancer recurrence at 2 years after pancreatic surgery of 54.4%, while this rate was 89.4% in the PV-positive group. Finally, an elevated presurgical serum CA19-9 level (>700 IU/mL) was found to be significantly associated with a poor outcome after surgery in pancreatic cancer patients with pathological portosplenomesenteric venous invasion.

CONCLUSIONS

Pancreatic cancer carries a high risk of recurrence even if surgical resection is technically possible. The current study suggested that portosplenomesenteric involvement and preoperative high serum CA19-9 are poor prognostic indications; however, the findings provided little insight into the role of neoadjuvant therapy in such patients.

Right posterior approach for pancreaticoduodenectomy: a new technical approach

CONTEXT

The major goals that must be achieved during pancreaticoduodenectomy (PD) include reduction of postoperative hemorrhage and/or operating time. We herein describe a new technique for PD examining right posterior approach PD.

METHODS

From January 2012 to December 2013, 116 patients underwent PD for periampullary or pancreatic disease. Of these 116 patients, 56 cases were surgically treated for pancreas head or periampullary malignancy and were studied for blood loss volume and length of operation.

RESULTS

An interesting issue in the present study was related to operating time and intra-operative blood loss. The median blood loss volume and operating time were 349 mL (35-3,636 mL) and 276 min (188-467 min), respectively, in patients who underwent a right posterior-approach PD.

CONCLUSION

The estimated operative blood loss volume and operative time are lower in right posterior approach PD, probably due to clearly detection a route of the inferior pancreaticoduodenal artery from the SMA and following early ligation of the inferior pancreaticoduodenal artery and reduced congestion of the pancreatic head.

Long-term survival following pancreatectomy and s-1 chemotherapy for pancreatic acinar cell carcinoma with peritoneal dissemination: a case report and literature review

Current case is the third report of S-1 chemotherapy against acinar cell carcinoma (ACC) of pancreas, and our patient has achieved the longest reported recurrence-free survival, longer than 6 years, despite the presence of disseminated nodules at laparotomy.A 77-year-old man presented with abdominal discomfort. Computed tomography showed a low-density tumor in the pancreas tail and the patient was referred for surgery. A 3-cm sized pancreatic tumor, with localized disseminated nodules, was detected on laparotomy. Distal pancreatectomy with concomitant resection of disseminated nodules was performed, and histopathological examination revealed an ACC. Oral S-1 chemotherapy was administered postsurgery, and the patient showed no sign of recurrence during 73 months of follow-up. This is the first report of long-term survivor of pancreatic ACC with peritoneal dissemination, following pancreatectomy and S-1 chemotherapy.Current case suggests a beneficial effect of S-1 chemotherapy in cases of ACC.

Functional discrepancy between two liver lobes after hemilobe biliary drainage in patients with jaundice and bile duct cancer: an appraisal using (99m)Tc-GSA SPECT/CT fusion imaging

PURPOSE

To determine the functional discrepancy between the two liver lobes using technetium 99m ((99m)Tc) diethylenetriamine-pentaacetic acid-galactosyl human serum albumin ( GSA diethylenetriamine-pentaacetic acid-galactosyl human serum albumin ) single photon emission computed tomography (SPECT)/computed tomography (CT) fusion imaging following preoperative biliary drainage and portal vein embolization ( PVE portal vein embolization ) in patients with jaundice who have bile duct cancer ( BDC bile duct cancer ).

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board, with waiver of informed consent. Preoperative (99m)Tc- GSA diethylenetriamine-pentaacetic acid-galactosyl human serum albumin SPECT/CT fusion images from 32 patients with extrahepatic BDC bile duct cancer were retrospectively reviewed. Patients were classified into four groups according to the extent of biliary drainage and presence of a preoperative right PVE portal vein embolization : right lobe drainage group (right drainage), bilateral lobe drainage group (bilateral drainage), left lobe drainage group (left drainage), and left lobe drainage with right PVE portal vein embolization group (left drainage with right PVE portal vein embolization ). Percentage volume and percentage function were measured in each lobe using fusion imaging. The ratio between percentage function and percentage volume (the function-to-volume ratio) was calculated for each lobe, and the results were compared among the four groups. Statistical analysis was performed with Wilcoxon signed-rank tests and Mann-Whitney U tests.

RESULTS

The median values for the function-to-volume ratio in the right drainage, bilateral drainage, left drainage, and left drainage with right PVE portal vein embolization group were 1.12, 1.05, 1.02, and 0.81 in the right lobe; and 0.51, 0.88, 0.96, and 1.17 in the left lobe. Significant differences in the function-to-volume ratio were observed among the four groups (right drainage vs bilateral drainage vs left drainage vs left drainage with right PVE portal vein embolization ; with P < .002, P = .023, and P < .002 for the right lobe and P < .001, P = .023, and P < .002 for the left lobe).

CONCLUSION

Hepatic lobar function significantly differs between the two lobes, depending on the extent of biliary drainage and the presence of portal vein embolization.

Surgical outcomes for 131 cases of carcinosarcoma of the hepatobiliary tract

Carcinosarcoma of the hepatobiliary tract is highly aggressive and has a poor prognosis even after curative resection. The purpose of this study was to collate and analyze published data to clarify the surgical outcome of carcinosarcoma of the hepatobiliary tract and the relationships between potential prognostic factors and survival after surgery. We surveyed worldwide literature from 1970 to 2012 and obtained clinicopathological data for 131 patients who had undergone surgical resection for carcinosarcoma of the hepatobiliary tract, including one patient from our clinic. The relationships between potential prognostic factors and survival rates were examined using the Kaplan-Meier method and the log-rank test. The overall 1-, 3-, and 5-year survival rates for patients with carcinosarcoma of the hepatobiliary tract after surgery were 44.0, 29.3, and 27.0 %, respectively. In univariate analyses, age and gender were not significant prognostic factors; however, advanced stage according to the classification of the Union for International Cancer Control in resected specimens was significantly associated with a shorter survival time after surgery. Although carcinosarcoma of the hepatobiliary tract remains a rare disease worldwide, its poor prognosis, even after curative resection, demands further epidemiological and pathological study that could lead to the development of new management strategies.

Intensive versus intermediate glucose control in surgical intensive care unit patients

OBJECTIVE

The optimal perioperative blood glucose range to improve surgical site infection (SSI) in surgical intensive care unit (ICU) patients remains unclear. We sought to determine whether the incidence of SSI is reduced by perioperative intensive insulin therapy (IT).

RESEARCH DESIGN AND METHODS

Patients were randomly assigned to receive perioperative intensive IT, with a target blood glucose range of 4.4-6.1 mmol/L, or intermediate IT, with a target blood glucose range of 7.7-10.0 mmol/L in the surgical ICU. We defined the primary end point as the incidence of SSI.

RESULTS

Study participants were randomly assigned to glucose control with one of two target ranges: for 225 patients in the intermediate IT group or for 222 patients in the intensive IT group, respectively. No patients in either group became hypoglycemic (<4.4 mmol/L) during their stay in the surgical ICU. In our series, the rate of SSI after hepato-biliary-pancreatic surgery was 6.7%. Patients in the intensive IT group, compared with the intermediate IT group, had fewer postoperative SSIs (9.8% vs. 4.1%, P = 0.028) and a lower incidence of postoperative pancreatic fistula after pancreatic resection (P = 0.040). The length of hospitalization required for patients in the intensive IT group was significantly shorter than that in the intermediate IT group (P = 0.017).

CONCLUSIONS

We found that intensive IT decreased the incidence of SSI among patients who underwent hepato-biliary-pancreatic surgery: a blood glucose target of 4.4 to 6.1 mmol/L resulted in lower rate of SSI than did a target of 7.7-10.0 mmol/L.

Extrahepatic stem cells mobilized from the bone marrow by the supplementation of branched-chain amino acids ameliorate liver regeneration in an animal model

BACKGROUND AND AIMS

In recent years, bone marrow (BM)-derived stem cell repopulation of injured organs has been increasingly observed; however, the extent to which it occurs and its clinical relevance remain unclear. Here, we investigated on the potential of extrahepatic stem cells to become hepatocytes using the treatment of the oral supplementation of branched-chain amino acids (BCAA).

METHODS

In the first, Sprague-Dawley (SD) rats were administered BCAA to promote liver regeneration; in the second, syngenic liver transplantations using wild-type SD rats that do not express green fluorescent protein (GFP) as syngenic donors and GFP-transgenic SD rats as recipients to confirm that an extrahepatic source of cells (GFP(+)) could repopulate the transplanted (GFP(-)) liver were performed.

RESULTS

Treatment of the oral supplementation of BCAA for 2-3 weeks before transplantation to promote liver regeneration resulted in greater than 7 days graft volume, with extensive spotty conversion of a small wild-type graft to the recipient GFP(+) genotype. The treatment by oral supplementation of BCAA resulted in higher levels of CD34+SDF+c-kit+ stem cells in the blood and liver after liver transplantation. Liver repopulation could be achieved with hepatocytes that bone marrow-derived from stem cells proliferated.

CONCLUSIONS

We have identified extrahepatic stem cell migration from the BM to the injured liver as a mechanism underlying liver regeneration that supports hepatocyte proliferation in diseased liver. Our results suggested that BCAA is able to mobilize a population of BM-derived cells that contribute to hepatic regeneration.

A Case Report of Hepatocellular Carcinoma in a Non-cirrhotic Patient With Liver Iron Overload Associated With Myelodysplastic Syndrome

Hereditary hemochromatosis (HH) is associated with an increased risk for hepatocellular carcinoma (HCC) occurring predominantly in patients with cirrhosis at the time of diagnosis. However, HCC in non-cirrhotic liver of patients with secondary hemochromatosis is rare. A 67-year-old man with a history of myelodysplastic syndrome (MDS) was found to have a liver tumor on abdominal computed tomography (CT). On the basis of findings of high levels of serum ferritin and transferrin saturation, and low intensity of liver parenchyma on magnetic resonance imaging (MRI), we made a diagnosis of hemochromatosis. Liver resection was performed and the specimen showed moderately differentiated hepatocellular carcinoma surrounded by non-cirrhotic liver parenchyma with intracellular iron deposition. Multicentric recurrence of liver tumor occurred 2 years after the surgery despite of deferoxamine therapy with well controlled ferritin level. We reported a case of hepatocellular carcinoma in a non-cirrhotic patient with liver iron overload secondary to MDS. It demonstrated the importance of early detection and initiation of treatment of iron overload in preventing HCC in MDS patients, even among Asian population.

Heterotopic pancreas in the common bile duct, with a review of the literature

A 65-year-old man presented with upper abdominal pain and was suspected of having choledocholithiasis. Endoscopic extraction of the stone was performed; however, a round filling defect in the common bile duct (CBD) persisted. Subsequent cholangioscopy showed the presence of a papillary tumor in the CBD, and the lesion was removed via the Whipple procedure. Microscopically, the papillary lesion was composed of pancreatic tissue in the submucosal layer of the CBD and therefore diagnosed as reflective of heterotopic pancreas. This is only the seventh case of heterotopic pancreas in the CBD reported in the English literature.

Endovascular pseudoaneurysm repair after distal pancreatectomy with celiac axis resection

Erosive hemorrhage due to pseudoaneurysm is one of the most life-threatening complications after pancreatectomy. Here, we report an extremely rare case of rupture of a pseudoaneurysm of the common hepatic artery (CHA) stump that developed after distal pancreatectomy with en block celiac axis resection (DP-CAR), and was successfully treated through covered stent placement. The patient is a 66-year-old woman who underwent DP-CAR after adjuvant chemoradiotherapy for locally advanced pancreatic body cancer. She developed an intra-abdominal abscess around the remnant pancreas head 31 d after the surgery, and computed tomography (CT) showed an occluded portal vein due to the spreading inflammation around the abscess. Her general condition improved after CT-guided drainage of the abscess. However, 19 d later, she presented with melena, and CT showed a pseudoaneurysm arising from the CHA stump. Because the CHA had been resected during the DP-CAR, this artery could not be used as the access route for endovascular treatment, and instead, we placed a covered stent via the inferior pancreaticoduodenal artery originating from the superior mesenteric artery. After stent placement, cessation of bleeding and anterograde hepatic artery flow were confirmed, and the patient recovered well without any further complications. CT angiography at the 6-mo follow-up indicated the patency of the covered stent with sustained hepatic artery flow. To our knowledge, this is the first reported case of endovascular repair of a pseudoaneurysm that developed after DP-CAR.

Comparison of pancreatic acinar cell carcinoma and adenocarcinoma using multidetector-row computed tomography

AIM: To distinguish acinar cell carcinoma (ACC) from pancreatic adenocarcinoma (AC) by comparing their computed tomography findings.

METHODS: Patients with ACC and AC were identified on the basis of results obtained using surgically resected pancreatectomy specimens. The preoperative computer tomographic images of 6 acinar cell carcinoma patients and 67 pancreatic adenocarcinoma patients in 4 phases (non-contrast, arterial, portal venous, and delayed phase) were compared. The scan delay times were 40, 70, and 120 s for each contrast-enhanced phase. The visual pattern, tomographic attenuation value, and time attenuation curve were assessed and compared between AC and ACC cases using the χ² test, Wilcoxon signed-rank test, and Mann Whitney U test.

RESULTS: The adenocarcinomas tended to be hypodense in all 4 phases. The acinar cell carcinomas also tended to be hypodense in the 3 contrast-enhanced phases, although their computed tomographic attenuation values were higher. Further, 5 of the 6 acinar cell carcinomas (83%) were isodense in the non-contrast phase. The time attenuation curve of the adenocarcinomas showed a gradual increase through the 4 phases, and all adenocarcinomas showed peak enhancement during the delayed phase. The time attenuation curve of the acinar cell carcinomas showed peak enhancement during the portal venous phase in 4 cases and during the arterial phase in 2 cases. None of the 6 acinar cell carcinomas showed peak enhancement during the delayed phase.

CONCLUSION: The tumor density in the non-contrast phase and time attenuation curve pattern clearly differ between acinar cell carcinomas and adenocarcinomas, and multidetector-row computed tomography can thus distinguish these tumors.

CT/99mTc-GSA SPECT fusion images demonstrate functional differences between the liver lobes

AIM: To evaluate the functional differences between the 2 liver lobes in non-cirrhotic patients by using computed tomography/^99mTc-galactosyl human serum albumin (CT/^99mTc-GSA) single-photon emission computed tomography (SPECT) fusion images.

METHODS: Between December 2008 and March 2012, 264 non-cirrhotic patients underwent preoperative liver function assessment using CT/^99mTc-GSA SPECT fusion images. Of these, 30 patients, in whom the influence of a tumor on the liver parenchyma was estimated to be negligible, were selected. Specifically, the selected patients were required to meet either of the following criteria: (1) the presence of an extrahepatic tumor; or (2) presence of a single small intrahepatic tumor. These 30 patients were retrospectively analyzed to calculate the percentage volume (%Volume) and the percentage function (%Function) of each lobe. The ratio between the %Function and %Volume (function-to-volume ratio) of each lobe was also calculated, and the ratios were compared between the 2 lobes. Furthermore, the correlations between the function-to-volume ratio and each of 2 liver parameters [lobe volume and diameter ratio of the left portal vein to the right portal vein (LPV-to-RPV diameter ratio)] were investigated.

RESULTS: The median values of %Volume and %Function were 62.6% and 67.1% in the right lobe, with %Function being significantly higher than %Volume (P < 0.01). The median values of %Volume and %Function were 31.0% and 28.7% in the left lobe, with %Function being significantly lower than %Volume (P < 0.01). The function-to-volume ratios of the right lobe (1.04-1.14) were significantly higher than those of the left lobe (0.74-0.99) (P < 0.01). The function-to-volume ratio showed no significant correlation between the lobe volume in either lobe. In contrast, the function-to-volume ratio showed significant correlations with the LPV-to-RPV diameter ratio in both lobes (right lobe: negative correlation, r_s = -0.37, P = 0.048; left lobe: positive correlation, r_s = 0.71, P < 0.001). The function-to-volume ratio in the left lobe tended to be higher, and that in the right lobe tended to be lower, in accordance with the increase in the LPV-to-RPV diameter ratio.

CONCLUSION: CT/^99mTc-GSA SPECT fusion images demonstrated that the function of the left lobe was significantly decreased compared with that of the right lobe in non-cirrhotic livers.

Invasive carcinoma derived from branch duct-type IPMN may be a more aggressive neoplasm than that derived from main duct-type IPMN

The present study aimed to evaluate the long-term follow-up results of patients with intraductal papillary mucinous neoplasm (IPMN) and to estimate the degree of IPMN malignancy based on pathological and molecular features of resected specimens. The detection rate of IPMN has increased over the last decade; however, the management of this neoplasm remains controversial. This is particularly so for branch duct-type IPMN, which carries a high potential for malignancy and risk of recurrence. We retrospectively reviewed a single institution’s prospective pancreatic resection database to identify IPMN patients who underwent pancreatectomy with curative intent. The clinicopathological variables of 100 patients resected for IPMN were analyzed with a detailed review of histopathological results (borderline lesions, non-invasive carcinoma and invasive carcinoma) to determine the grade of IPMN malignancy based on transforming growth factor (TGF)-β/SMAD4 signaling. The incidence of malignant change was significantly higher in patients with main duct-type IPMN (69.7%) compared with branch duct-type IPMN cases (17.9%). However, patients with an invasive carcinoma had a significantly worse outcome if it was derived from branch duct-type IPMN compared with those derived from main duct-type IPMN, and TGF-β mRNA expression was significantly increased in the former patient group. Immunohistochemistry also showed higher numbers of SMAD4-positive cells in patients with carcinoma derived from branch duct-type IPMN. Our results demonstrated that invasive carcinoma derived from branch duct-type IPMN is more aggressive than that derived from main duct-type IPMN, once invasive morphological change takes place. Determining TGF-β and/or SMAD4 status at initial diagnosis may be useful for stratifying IPMN patients into treatment regimens.

Diagnosis and management of insulinoma

Insulinomas, the most common cause of hypoglycemia related to endogenous hyperinsulinism, occur in 1-4 people per million of the general population. Common autonomic symptoms of insulinoma include diaphroresis, tremor, and palpitations, whereas neuroglycopenenic symptoms include confusion, behavioural changes, personality changes, visual disturbances, seizure, and coma. Diagnosis of suspected cases is based on standard endocrine tests, especially the prolonged fasting test. Non-invasive imaging procedures, such as computed tomography and magnetic resonance imaging, are used when a diagnosis of insulinoma has been made to localize the source of pathological insulin secretion. Invasive modalities, such as endoscopic ultrasonography and arterial stimulation venous sampling, are highly accurate in the preoperative localization of insulinomas and have frequently been shown to be superior to non-invasive localization techniques. The range of techniques available for the localization of insulinomas means that blind resection can be avoided. Intraoperative manual palpation of the pancreas by an experienced surgeon and intraoperative ultrasonography are both sensitive methods with which to finalize the location of insulinomas. A high proportion of patients with insulinomas can be cured with surgery. In patients with malignant insulinomas, an aggressive medical approach, including extended pancreatic resection, liver resection, liver transplantation, chemoembolization, or radiofrequency ablation, is recommended to improve both survival and quality of life. In patients with unresectable or uncontrollable insulinomas, such as malignant insulinoma of the pancreas, several techniques should be considered, including administration of ocreotide and/or continuous glucose monitoring, to prevent hypoglycemic episodes and to improve quality of life.

Technical challenges and clinical outcomes of using a closed-loop glycemic control system in the hospital

According to large randomized trials, results suggest that maintaining normoglycemia postoperatively through tight glycemic control (TGC) and intensive insulin therapy (IIT) can improve surgical outcomes as well as reduce mortality and morbidity in critically ill patients. However, trials examining the effects of TGC have had conflicting results. Systematic reviews and meta-analyses have also led to differing conclusions. The main reason these clinical trials and meta-analyses show negative results for TGC is the high incidence of hypoglycemia induced by IIT. This could not be prevented because there is no reliable technique that can avoid this condition during IIT. The development of accurate, continuous blood glucose monitoring devices and closed-loop systems for computer-assisted blood glucose control in the intensive care unit (ICU) will probably help avoid hypoglycemia in these situations. The STG closed-loop glycemic control system was introduced to our department to be used and evaluated for strict serum glucose control with no hypoglycemic episodes during IIT in the surgical ICU, to reduce the workload of ICU nurses, and to decrease incidents related to the management of blood glucose levels according to manual conventional venous infusion insulin therapy. The goal of our team was to use the STG closed-loop glycemic control system for perioperative TGC in surgical patients to solve the complications of IIT and reduce risk of hypoglycemia. The challenge at our hospital demonstrated that the STG closed-loop glycemic control system can be expected to achieve TGC with no occurrence of hypoglycemia induced by IIT after surgery.

Primary liposarcoma of the duodenum: a first case presentation

A 55-year-old man suffering from melena was admitted to our hospital. A blood test showed severe anemia. Contrast-enhanced computed tomography (CT) revealed a huge lesion in the duodenum and dilatation of the common bile duct. Upper gastrointestinal endoscopy also identified hemorrhaging from the tumor in the duodenum. Due to the low density of the tumor mass, we performed emergency pylorus-preserving pancreaticoduodenectomy. Histology revealed an area of well-differentiated liposarcoma as well as an area of high-grade spindle cells and pleomorphic sarcoma without obvious differentiation. The final pathological diagnosis was dedifferentiated liposarcoma. This is the first case report of primary liposarcoma of the duodenum.

Necrotic hepatocellular carcinoma occurring within an inflammatory pseudotumor-like nodule

Hepatocellular carcinoma (HCC) and inflammatory pseudotumor of the liver (IPL) are often difficult to differentiate before surgery. To date, colocalization of IPL and HCC has not been reported. We experienced a case of necrotic HCC surrounded by IPL-like tissue. The raised levels of alpha-fetoprotein and PIVKA-II declined to within the normal ranges after resection of the tumor. The IPL-like nodule most likely developed as a process of an inflammatory reaction such as abscess formation after the spontaneous destruction of the HCC. Our case is a warning that the presence of a 'pseudotumor' does not rule out the possible simultaneous presence of carcinoma.

Synchronous double cancers of the common bile duct

We report an extremely rare case of synchronous double cancers of the common bile duct without pancreaticobiliary maljunction. Only two similar cases have been reported in the English literature. Endoscopic re-trograde cholangiopancreatography showed a tuberous filling defect in the middle and superior parts of the common bile duct, and mild stenosis in the inferior duct. Computed tomography (CT) showed a well enhanced mass in the middle and superior parts of the common bile duct. A single cancer of the middle and superior bile duct was suspected and extra-hepatic bile duct resection was performed. CT eleven months after surgery revealed enhanced inferior bile duct wall and a slightly enhanced tumor within it. Retrospective review of the CT images taken before first surgery showed enhanced inferior bile duct wall without intrabiliary tumor only on the delayed phase. The inferior bile duct tumor was suspected to have originally co-existed with the middle and superior bile duct tumor. Pancreaticoduodenectomy was performed subsequently. Histopathological examination revealed that the middle and superior bile duct tumor was a moderately differentiated tubular adenocarcinoma while the inferior bile duct tumor was a papillary adenocarcinoma. The two tumors were separated and had different histological findings and growth patterns, further suggesting that they were two primary cancers.