Naoki Ishizaki

Multiple duodeno-jejunal diverticula causing massive intestinal bleeding.

Abstract: A case of massive intestinal blood loss from multiple duodeno-jejunal diverticula is described. A 39-year-old man was referred to our hospital because of recurrent bloody stool and worsening anemia. Upper and lower endoscopy, selective abdominal angiography, and radionuclide scanning were performed to seek the cause of the intestinal bleeding, but none of these studies revealed the source of bleeding. Small-bowel barium follow-through examination showed numerous diverticula in the distal duodenum and proximal jejunum. Excision of the duodenal diverticulum and resection of the involved portion of the jejunum cured the patient. On histopathological examination, an ulcerative lesion with an exposed vessel suggestive of the source of bleeding was seen in the resected duodenal diverticulum. Although duodeno-jejunal diverticula are rare, the importance of a careful search for this malformation in a patient with intestinal blood loss is stressed.

Ruptured bronchial artery aneurysm associated with pleural telangiectasis and tortuous portal obstruction : report of a case

A 25-year-old woman presenting with an emergent condition of massive hemothorax due to a ruptured bronchial artery aneurysm was successfully treated by transcatheter arterial embolization. She had previously undergone portosystemic shunt splenopneumopexy for hepatic portal hypertension at 6 years of age. When undergoing right thoracotomy for the removal of a clot, a prominent telangiectasis on the pleural surface was noted. The lesion appeared to be a rare systemic vascular abnormality although this could not be confirmed.

SPONTANEOUS SUBCAPSULAR HEPATIC HEMORRHAGE ASSOCIATED WITH PREGNANCY : REPORT OF A CASE

We report herein a case of spontaneous subcapsular hepatic hemorrhage which occurred in a 33-year-old woman 1 day after she had been delivered of her second child by cesarean section following an uneventful pregnancy. She complained of right upper quadrant pain on the 1st postoperative day, and computed tomography (CT) showed subcapsular low-density masses in both liver lobes, while extravasation was demonstrated by CO2 intraarterial digital subtraction angiography (IADSA). The hemorrhage was successfully controlled by transcatheter arterial embolization (TAE). However, on the 3rd day after TAE, an exploratory laparotomy was performed to establish an exact diagnosis to explain the persistent abdominal pain and abnormal liver function tests. Subcapsular hematomas in both lobes were confirmed and no visible laceration was present. The patient recovered gradually by spontaneous absorption of the hematomas and was discharged on the 22nd postoperative day. Spontaneous hepatic hemorrhage associated with pregnancy is a very rare complication, and establishing a correct diagnosis and initiating appropriate therapy are essential for this life-threatening disease.

Simultaneous repair of an abdominal aortic aneurysm and resection of bronchogenic carcinoma: Report of a case

A 69-year-old man successfully underwent simultaneous repair of an abdominal aortic aneurysm and resection of bronchogenic carcinoma during the same operation. Pulmonary lobectomy was performed following complete closure of the abdomen after aneurysmectomy to prevent any contamination. If the patients are carefully selected, an operation for abdominal aortic aneurysm and bronchogenic carcinoma can be safely performed with the advantage of treating both lesions simultaneously and thus sparing the patients from having to undergo the physical and psychosomatic pain, as well as the risk, of a second operation.

A new animal model for split liver transplantation using an infrahepatic IVC graft.

An animal model of split liver transplantation using pigs is described herein. The donor liver was divided into two grafts, the right graft consisting of the right medial and lateral segments with the caudate lobe, and the left graft consisting of the left lateral and medial segments. To make implantation easier, a distal part of the donors inferior vena cava (IVC) was isolated and attached to the left graft with an anastomosis between the orifice of the renal vein and the grafts hepatic vein. The left graft thereby contained a newly constructed retrohepatic IVC for anastomosis to the recipient. During the anhepatic phase, no conventional bypass procedure was used, but an abdominal aortic clamp in combination with general hypothermia was employed. Ten pigs were used as donors and a total 20 liver transplantations performed. No immunosuppressive drugs were given in this series. Ten of the 20 recipients survived for more than 2 days, the mean survival time being 4.7 days, with a range of 2–14 days. The mean survival time of the left grafts was much longer than that of the right grafts, although no technical problems such as kinking of the graft or occlusion of the hepatic vein were encountered in either. This model is the first report of split liver transplantation in animals. The advantages of using the infrahepatic IVC graft include stability of the graft and safe hepatectomy. This model will therefore be useful for the experimental study of split liver transplantation and may also be employed for clinical use in the future.

Recurrent nonocclusive mesenteric ischemia after resection of iliac artery aneurysm

A case of recurrent nonocclusive mesenteric ischemia in a patient with isolated internal iliac artery aneurysm penetrating the sigmoid colon is described. On the day after the aneurysm and the sigmoid colon had been resected, the patient developed necrosis of the left hemicolon. Fourteen and nineteen days after left hemicolectomy, massive intestinal bleedings occurred, requiring ileectomy. On the basis of operative findings of good pulsation of visceral arterial branches; angiography showing patent mesenteric vessels with some spasms; and pathological findings suggesting mesenteric ischemia, these ischemic events were diagnosed as nonocclusive mesenteric ischemia. Low-output syndrome induced by massive intestinal bleeding and atrial fibrillation and sepsis were responsible for the establishment of the nonocclusive mesenteric ischemia. Development of disseminated intravascular coagulation and continuous administration of diuretics for acute renal failure seemed to have further perturbed the mesenteric circulation. The patient died of subsequent multiple organ failure 4 months after the first operation. We should pay more attention to nonocclusive mesenteric ischemia in patients with mesenteric ischemia, and strict circulatory management during the perioperative period is essential in these patients.

Liver injury and serotonin production after small intestinal ischemia and reperfusion.

IT IS well known that numerous mediators derived from intestinal ischemia/reperfusion (I/R) implicates as the factors in multiple organ damages. Serotonin (5hudroxytryptamin, 5-HT), synthesized in the enterochromaffin cells in the intestine and stored in platelets, is known to play an important role in vasoconstriction and platelet aggregation, and may lead to enhance such organ injuries. It has been demonstrated that 5-HT infusion into the portal vein induced contraction of fenestrae of liver sieve plates and increased vascular resistance in the liver. The purpose of this study was to investigate the association between liver damage and 5-HT production after intestinal I/R.

Late massive hemorrhage following cystogastrostomy for pancreatic pseudocyst: Report of a case

We report the case of a man who developed life-threatening massive gastric hemorrhage 3 months after undergoing cystogastrostomy for a pancreatic pseudocyst. After cystogastrostomy, the pancreatic pseudocyst became remarkably reduced in size, having the appearance of a shallow ulcer by barium study. However, tarry stools and hematemesis developed 3 months later, 6 days after which sudden massive hematemesis and melena occurred with severe hypotension. At emergency operation, a large artery at the bottom of the reduced cyst wall was found to have ruptured and hemostasis was achieved by suture ligation. The splenic artery was suspected as the bleeding point because a 95% abrupt stenosis was seen on angiography-performed the next day. Thus, the risk of hemorrhage occurring after internal drainage of a pancreatic pseudocyst even in the late postoperative period should always be borne in mind.

Extended central bisegmentectomy—an en bloc resection of hepatic segments 4, 5, 8 and 7: Report of a case

We herein present an example of an extended central bisegmentectomy in a patient with a large hepatocellular carcinoma. According to a magnetic resonance imaging study, the right hepatic vein was displaced and narrowed at its origin and a large inferior right hepatic vein was revealed. In this case, owing to the only slightly functional remaining hepatic reserve, an extended central bisegmentectomy was selected as the optimum treatment. The postoperative course was uneventful except for some bile leakage. Twelve months after operation, the patient is still alive and no sign of recurrence has been detected.The extended central bisegmentectomy is an en bloc resection of hepatic segments 4, 5, 7, and 8. When the large inferior right hepatic vein is present, segment 6 can be preserved even when the right hepatic vein is sacrificed at its origin.

A Case of Superior Mesenteric Artery Thrombosis Associated With Transient Elevation of Antiphospholipid Antibodies

Transient elevation of antiphospholipid antibody (APLA) is commonly observed in cases of viral infection; however, it is generally not associated with clinical thromboembolic events. In this report, we present a rare case of superior mesenteric artery (SMA) thrombosis associated with a transient elevation of APLA and discuss its relationship with fibromuscular dysplasia and adenomyosis of the uterus. Furthermore, we discuss the use of anticoagulant therapy in cases with transient elevation of APLA. In this case, a 46-year-old woman with no significant medical history was diagnosed with intestinal stenosis after SMA thrombosis that had been resolved with anticoagulant therapy. Laboratory examination showed elevated levels of anticardiolipin antibody. Resection of the stenosed ileum and hysterectomy for huge adenomyosis were performed. Anticardiolipin antibody level normalized 4 months after the operation. Anticoagulant therapy was withdrawn after anticardiolipin antibody normalized, and the patient has bee...