Manabu Nakata

Important surgical measures and techniques at cesarean hysterectomy for placenta previa accreta

For cesarean hysterectomy with placenta previa accreta, “universally achievable” measures are required. We propose eight measures: (i) placement of intra‐iliac arterial occlusion balloon catheters; (ii) placement of ureter stents; (iii) “holding the cervix” to identify the site to be transected; (iv) uterine fundal incision; (v) avoidance of uterotonics; (vi) “M cross double ligation” for ligating the ovarian ligament; (vii) “filling the bladder” to identify the bladder separation site and “opening the bladder” for placenta previa accreta with bladder invasion; and (viii) to continue to clamp the medial side of the parametrium or the cervix or employment of the “double edge pick‐up” to ligate it. These eight measures are simple, easy, effective, and thus “universally achievable”.

Uterine artery pseudoaneurysm: not a rare condition occurring after non-traumatic delivery or non-traumatic abortion

PurposeUterine artery pseudoaneurysm (UAP) is considered a rare disorder after traumatic delivery or traumatic pregnancy termination such as cesarean section or dilatation and curettage, initially manifesting as genital hemorrhage. Our clinical impression contradicts these three assumptions; after traumatic delivery/termination, hemorrhage, and its rarity. Thus, we attempted to clarify these three issues.MethodsWe retrospectively analyzed 22 UAP cases treated at our institute over a 6-year period.ResultsUterine artery pseudoaneurysm occurred in 2–3/1,000 deliveries. Of 22 cases, half occurred after non-traumatic deliveries or non-traumatic pregnancy termination. Fifty-five percent (12/22) showed no hemorrhage; ultrasound or color Doppler revealed UAP. Thus, half of UAP occurred after non-traumatic deliveries or non-traumatic pregnancy termination and showed no hemorrhage at the time of their diagnoses. All patients received transarterial embolization, which stopped blood flow into UAP or achieved hemostasis.ConclusionWe must be aware that UAP may not be so rare and it may be present in patients after non-traumatic deliveries/pregnancy termination and without postpartum or postabortal hemorrhage.

Asymptomatic uterine artery pseudoaneurysm after cesarean section.

Uterine artery pseudoaneurysm is a rare but important complication of cesarean section (CS). If treated inadequately, it may cause profuse life‐threatening postpartum hemorrhage. We report an asymptomatic postpartum woman with uterine artery pseudoaneurysm after CS. We also provide a review of published reports of pseudoaneurysm after CS. A 31‐year‐old Japanese woman underwent CS, in which the uterine incision was extended laterally. Routine postoperative evaluation with vaginal ultrasound on postpartum day 6 revealed a parauterine mass with a maximum diameter of 49 mm with swirling flow. Selective angiography confirmed this mass as a uterine artery pseudoaneurysm. Uterine artery embolization was performed with success. Uterine artery pseudoaneurysm should be listed as a differential diagnosis of pelvic mass after CS.

Opening the bladder for cesarean hysterectomy for placenta previa percreta with bladder invasion

Cesarean hysterectomy for placenta previa percreta with bladder invasion often induces not only massive hemorrhage but also severe bladder/ureter injuries. A 37‐year‐old woman with previous cesarean delivery suffered placenta previa percreta with bladder invasion. At the 34th week, we performed cesarean hysterectomy. Without separating the bladder from the uterus/cervix, we incised the bladder lateral wall using an automatic stapling/cutting device, leaving the bladder posterior wall adhering to the uterus and resecting it with the uterus. The bladder was easily repaired without urological sequelae. We suggest a new, simple and safe technique for cesarean hysterectomy for this disease.

Living-Donor Liver Transplantation in 126 Patients with Biliary Atresia: Single-Center Experience

OBJECTIVES To describe our experience with 126 consecutive living-donor liver transplantation (LDLT) procedures performed because of biliary atresia and to evaluate the optimal timing of the operation. PATIENTS AND METHODS Between May 2001 and January 2010,126 patients with biliary atresia underwent 130 LDLT procedures. Mean (SD) patient age was 3.3 (4.2) years, and body weight was 13.8 (10.7) kg. Donors included 64 fathers, 63 mothers, and 3 other individuals. The left lateral segment was the most commonly used graft (75%). Patients were divided into 3 groups according to body weight: group 1, less than 8 kg (n = 40); group 2,8 to 20 kg (n = 63); and group 3, more than 20 kg (n = 23). Medical records were reviewed retrospectively. Follow up was 4.5 (2.7) years. RESULTS All group 3 donors underwent left lobectomy, and all group 1 donors underwent left lateral segmentectomy. No donors required a second operation or died. Comparison of the 3 groups demonstrated that recipient Pediatric End-Stage Liver Disease score in group 1 was highest, operative blood loss in group 2 was lowest (78 mL/kg), and operative time in group 3 was longest (1201 minutes). Hepatic artery complications occurred more frequently in group 1 (17.9%), and biliary stenosis (43.5%) and gastrointestinal perforation (8.7%) occurred more frequently in group 3. The overall patient survival rates at 1, 5, and 9 years was 98%, 97%, and 97%, respectively. Five-year patient survival rate in groups 1,2, and 3 were 92.5%, 100%, and 95.7%, respectively. Gastrointestinal perforation (n = 2) was the primary cause of death. CONCLUSIONS Living-donor liver transplantation is an effective treatment of biliary atresia, with good long-term outcome. It seems that the most suitable time to perform LDLT to treat biliary atresia is when the patient weighs 8 to 20 kg.

Central venous stenosis among hemodialysis patients is often not associated with previous central venous catheters.

It is widely assumed that central venous stenosis (CVS) is most commonly associated with previous central venous catheterization among the chronic hemodialysis (HD) patients. We evaluated the validity of this assumption in this retrospective study. The clinical records from 2,856 consecutive HD patients with vascular access failure during a 5-year period were reviewed, and a total of 26 patients with symptomatic CVS were identified. Combined with radiological findings, their clinical characteristics were examined. Only seven patients had a history of internal jugular dialysis catheterization. Diagnostic multidetector row computed tomography angiography showed that 7 of the 19 patients with no history of catheterization had left innominate vein stenosis due to extrinsic compression between the sternum and arch vessels. These patients had a shorter period from the time of creation of the vascular access to the initial referral (9.2 ± 7.6 months) than the rest of the patients (35.5 ± 18.6 months, p = 0.0017). Our findings suggest that cases without a history of central venous catheterization may not be rare among the HD patients with symptomatic CVS. However, those still need to be confirm by larger prospective studies of overall chronic HD patients with symptomatic CVS.

Vaginal artery embolization with a permanent embolic agent for intractable postpartum hemorrhage.

Transcatheter arterial embolization has been used to achieve hemostasis for postpartum hemorrhage (PPH). In this journal, we described two patients in whom uterine artery embolization stopped the bleeding from a postpartum uterine artery pseudoaneurysm. Temporary embolic agents, absorbable gelatin sponges, have been widely employed, also by us; however, they have some disadvantages. Gelatin sponges physically block blood flow, inducing thrombus formation around the embolic material, thus requiring the host’s hemostatic capacity (clotting factors) for successful embolization. Clotting abnormalities, frequently associated with profound PPH, may prohibit thrombus formation and, thus, the achievement of hemostasis. Permanent embolic agents, working independently of the host’s hemostatic capacity, may achieve hemostasis even in a patient with clotting abnormalities. We report a patient with clotting abnormalities in whom vaginal artery embolization, using a non-absorbable permanent embolic agent, N-butyl cyanoacrylate (NBCA), stopped intractable PPH due to birth canal injury. Postpartum hemorrhage occurred from the laceration of the right vaginal wall, which was sutured without hemostasis. The patient was transferred to the ward, where her blood pressure was 80/50 mmHg and pulse rate 152 bpm. Laboratory data indicated anemia and clotting abnormalities: hemoglobin, 3.0 g/dL; platelets, 20 000/mL; activated partial thromboplastin time, 94 s. Ultrasound and computed tomography revealed a 11 ¥ 10 ¥ 10 cm mass in the pouch of Douglas’ compatible with intra-abdominal or retroperitoneal hematoma. The patient wanted to maintain fertility, and we explained the advantages and disadvantages of laparotomy and pelvic artery embolization, with the latter performed after obtaining informed consent. Contrast medium extravasated from the right vaginal artery (Fig. 1a). The catheter was placed in the right vaginal artery and 0.4 mL diluted NBCA was injected (Fig. 1b), which completely stopped the extravasation (Fig. 1c).

The role of operative intervention in management of congenital extrahepatic portosystemic shunt

BACKGROUND AND AIMS Congenital extrahepatic portosystemic shunt (CEPS) is a rare venous malformation in which mesenteric venous blood drains directly into the systemic circulation. It is still a matter of debate whether conservative or operative strategies should be used to treat symptomatic CEPS. The aim of this study was to evaluate the role of operative intervention in the management of CEPS. METHODS Between June 2004 and August 2010, 6 consecutive patients with symptomatic CEPS were treated in our department. There were 3 male and 3 female patients, with a median age of 3.5 years (range, 1-8). Their demographic, clinical, and laboratory data were analyzed. All patients were scheduled to undergo shunt ligation or liver transplantation (LT). RESULTS Living donor LT was carried out in 4 patients, and shunt ligation in 2. After a median follow-up of 25 months, all the patients are alive currently with marked relief of symptoms. CONCLUSION Shunt ligation or LT for symptomatic CEPS is potentially curative.

Adenomyomectomy, curettage, and then uterine artery pseudoaneurysm occupying the entire uterine cavity

Uterine artery pseudoaneurysm can occur after cesarean section or traumatic delivery, usually manifesting as postpartum hemorrhage. Pregnant women after adenomyomectomy sometimes suffer some adverse events, among which uterine rupture has been widely acknowledged. We describe a post‐abortive woman who had uterine artery pseudoaneurysm occupying the entire uterine cavity. She underwent adenomyomectomy and became pregnant. She experienced a missed abortion and underwent evacuation and curettage, which caused bleeding. Several days later, ultrasound revealed an intrauterine mass with marked blood flow. Angiography revealed the un‐ruptured left uterine artery pseudoaneurysm, with arterial embolization stopping the flow within the pseudoaneurysm. Adenomyomectomy with subsequent curettage was considered to have caused the pseudoaneurysm. We must be cautious that pseudoaneurysm may occur in post‐abortive women after adenomyomectomy.

Endovascular interventions for hepatic artery complications immediately after pediatric liver transplantation

Hepatic artery complications after living donor liver transplantation (LDLT) can directly affect both graft and recipient outcomes. For this reason, early diagnosis and treatment are essential. In the past, relaparotomy was generally employed to treat them. Following recent advances in interventional radiology, favorable outcomes have been reported with endovascular treatment. However, there is ongoing discussion regarding the best and safe time for definitive endovascular interventions. We herein report a retrospective analysis for six children with early hepatic artery complication after pediatric LDLT who underwent endovascular treatment as primary therapy at our institution. We evaluate the usefulness of endovascular treatment for hepatic artery complication and its optimal timing. The mean patient age was 11.9 months and mean body weight at LDLT was 6.7 kg. The mean duration between the transplantation and first endovascular treatment was 5.3 days. Five of the six patients were technically successful treated by only endovascular treatment. Of these five patients, two developed biliary complications. Endovascular procedures were performed 10 times in six patients without any complications and nine of the 10 procedures were successful. By selecting optimal devices, our findings suggest that endovascular treatment can be feasible and safe in the earliest time period after pediatric LDLT.