Nobuhiro Fujita

Postoperative Hyperbilirubinemia After Surgery for Gastrointestinal Perforation

Abstract.Abstract.Purpose: The aim of this study was to evaluate the risk factors and outcome of patients with hyperbilirubinemia after surgery for generalized peritonitis.Methods: We retrospectively analyzed data from 229 patients with generalized peritonitis caused by gastrointestinal (GI) perforations.Results: Postoperative hyperbilirubinemia defined as a value of ≧5 mg/dl, within 1 month, developed in 39 patients. Postoperative hyperbilirubinemia was related to age (P= 0.0102), poor nutritional status (P= 0.0388), decreased base excess (P= 0.0037), delay until surgery (P= 0.0276), preoperative serum bilirubin (P= 0.0321) and postoperative persistent infection (P < 0.0001). Higher mortality was seen in patients with hyperbilirubinemia (59%) than in those without hyperbilirubinemia (4%). The patients with hyperbilirubinemia who survived had decreased serum bilirubin levels after 3–5 postoperative days whereas a continuous increase was seen in the patients who ultimately died. Preoperative shock (P= 0.0003), a decreased preoperative platelet count (P= 0.0152), postoperative infection (P= 0.0050), and postoperative hyperbilirubinemia (P < 0.0001) were risk factors for overall mortality.Conclusion: These results indicate that postoperative hyperbilirubinemia in patients with GI perforation is related to persistent postoperative infection and associated with poor prognosis.

A multivariate analysis of the prognostic factors in severe liver trauma.

To examine the significance of physiologic and biochemical variables in liver trauma quantitatively, and to establish the early predictors of mortality according to the causes of death, 36 consecutive patients who underwent surgery for liver trauma between 1984 and 1993 were retrospectively studied. A univariate analysis revealed that shock, preoperative systolic blood pressure (SBP), preoperative alanine aminotransferase (ALT), the number of associated organ injuries, the Glasgow Coma Score (GCS), blood replacement requirements, and postoperative blood urea nitrogen (BUN) were significant prognostic factors of survival after liver trauma. However, a multivariate analysis indicated that GCS, postoperative BUN, the number of associated organ injuries, preoperative ALT, and SBP were independent prognostic factors. Because the causes of death after liver trauma can be divided into early hemorrhage and late sepsis, a multiple regression analysis of preoperative and postoperative variables was performed for each cause. The prognostic factors for hemorrhagic death were preoperative ALT, base excess, and the platelet count, whereas those for death due to sepsis were preoperative SBP and the presence of gastrointestinal injuries. These results suggest the value of measuring the preoperative serum level of ALT as a new independent prognostic factor for predicting overall and hemorrhagic death following severe liver trauma.

Granulocyte colony-stimulating factor for gastrointestinal perforation in patients with leukopenia.

OBJECTIVE Leukopenia in the setting of widespread infection may predispose to sepsis, which is associated with a poor prognosis. Granulocyte colony-stimulating factor (G-CSF), which restores polymorphonuclear leukocyte function and count, has been shown to have protective effects in animal models of sepsis and burns. The aim of this retrospective study was to determine whether G-CSF can reduce the morbidity and mortality gastrointestinal perforation with leukopenia. PATIENTS AND METHODS The studied subjects were 31 patients who had reduced leukocyte and neutrophil counts before undergoing surgery for gastrointestinal perforation, including six gastroduodenal, nine small intestinal, and 16 colonic perforations from 1986 to 1994. The patients were divided into two groups: a G-CSF(+) group (n = 8) that received G-CSF subcutaneously (150 microgram/day) during the perioperative period, and a G-CSF(-) group which did not. MAIN RESULTS No significant difference was found in the preoperative and operative factors of the two groups. The postoperative increase in the leukocyte and polymorphonuclear cell counts of the G-CSF(+) group was significantly higher than that of the G-CSF(-) group (p <0.01). Renal, hepatic, and gastrointestinal insufficiency was significantly less common in the G-CSF(+) group than in the G-CSF(-) group. The mean number of organs that failed was reduced from 4.00 +/- 2.50 in the G-CSF(-) group to 1.88 +/- 2.03 in the G-CSF(+) group. One of the eight patients who received G-CSF died of sepsis because of panperitonitis. In contrast, in the G-CSF(-) group, 15 of 23 patients died of sepsis because of panperitonitis. The cause-specific survival rate of the G-CSF(+) group was better than that of the G-CSF(-) group (p <0.05). CONCLUSION These results suggested that G-CSF reduced the morbidity and mortality of gastrointestinal perforation in patients with leukopenia and encouraged a prospective randomized study in future.

A giant subcutaneous leiomyosarcoma arising in the inguinal region

BackgroundSubcutaneous leiomyosarcoma is a rare condition that accounts for 1% to 2% of all superficial soft tissue malignancies. Approximately 10% of cases arise in the trunk, although the extremities are the most commonly affected.Case presentationWe report herein the case of a 31-year-old man with a subcutaneous leiomyosarcoma, measuring 124 × 105 mm, arising in the left inguinal region. A wide local excision (with a resection margin ≥ 20 mm) was performed. Histological examination of the resected specimen revealed a leiomyosarcoma with high cellularity and two mitoses per 10 high-power fields. The patient remains well with no evidence of disease 5 years and 8 months after the operation.ConclusionThis is the first reported case of subcutaneous leiomyosarcoma arising in the inguinal region and also one of the largest tumors reported. The experience of this case and a review of the English-language literature (PubMed, National Library of Medicine, Bethesda, MD, USA) suggest that a resection margin of ≥ 10 mm is recommended when excising this rare tumor.

Groove pancreatitis with recurrent duodenal obstruction

SummaryGroove pancreatitis is a rare subtype of chronic pancreatitis that is difficult to distinguish from pancreatic carcinoma. Most reported patients have undergone a Whipple procedure because pancreatic cancer was not ruled out. We report a case of groove pancreatitis in a patient who presented with recurrent duodenal obstruction without biliary stricture. The diagnosis of groove pancreatitis was based on characteristic episodes of repeated duodenal obstruction and the absence of radiographic evidence of cancer. Subsequently, our patient underwent a successful pylorus-reserving pancreaticoduodenectomy (PPPD). PPPD is a favorable alternative to the Whipple operation for duodenal obstruction resulting from this disease.

Clinical significance of splenectomy for colorectal cancer metastases to the spleen

AbstractBackground. The value of splenectomy for secondary splenic tumors remains unclear. The aim of this study was to disclose the clinical significance of splenectomy for colorectal cancer metastases to the spleen by reviewing our two patients and the 24 other patients reported thus far. Methods. We report two patients with splenic metastasis from colonic cancer. A review of 26 cases, including ours, was conducted. Results. One of our patients had isolated splenic metastasis and is alive with no evidence of disease 14 months after splenectomy, while the other had non-isolated splenic metastasis and died of disseminated disease 17 months after splenectomy. In the 26 patients overall, the outcome of those with isolated splenic metastasis (n = 20) was significantly better than that for those with non-isolated splenic metastasis (n = 6; P = 0.05). There were three long-term (more than 3 years) survivors; all three were patients with isolated splenic metastasis, with the longest survival being 110 months. Patients with mucinous carcinoma showed a better survival rate than patients with other histological types (P = 0.08). In patients with isolated metastasis, metastases after splenectomy occurred in the peritoneum (n = 3), liver (n = 1), and lung (n = 1) within 2 years. Conclusions. Splenectomy may provide long-term survival for patients with isolated colorectal cancer metastasis to the spleen. The mucinous variant may be a favorable prognostic factor after splenectomy. Recurrence after splenectomy is likely to occur within 2 years, mainly in the peritoneum.

Nonoperative treatment of reperforated duodenal ulcer: report of three cases.

Abstract During the period between 1983 and 1998, a total of 58 patients were admitted to the surgical department of Akita Red Cross Hospital with acute duodenal perforation. Of these 58 patients, 16 were treated operatively and 42 were treated nonoperatively. Among the 38 men and 4 women who received nonoperative treatment, 3 developed reperforation. The incidence of reperforation was 7.1% and the mean average interval from the initial treatment until reperforation was 3.5 years. Endoscopic biopsy and/or serum anti-H. pylori IgG measurement revealed Helicobacter pylori infection in all three patients. No serious complications developed during the nonoperative treatment of reperforation in these three patients, and their recovery was uneventful. The hospital stay ranged from 10 to 18 days, with a mean stay of 12 days after the first perforation and from 14 to 18 days, with a mean stay of 15.6 days after the reperforation. Nonoperative treatment proved successful as a life-saving procedure for reperforation of a duodenal ulcer in all three patients.

Complete Response of Isolated Para-aortic Lymph Node Recurrence from Rectosigmoid Cancer Treated by Chemoradiation Therapy with Capecitabine/Oxaliplatin plus Bevacizumab: A Case Report.

Para-aortic lymph node recurrence is a rare type of metastasis from colorectal cancer, and no treatment has yet been established. Here, we report on a case of isolated para-aortic lymph node metastasis from rectosigmoid cancer that showed complete response to chemoradiation therapy with capecitabine/oxaliplatin plus bevacizumab. A 58-year-old woman underwent high anterior resection for rectosigmoid cancer in 2009. Para-aortic lymph node recurrence occurred in 2011. She underwent radiation therapy (50 Gy) and 8 courses of capecitabine/oxaliplatin plus bevacizumab. Abdominal computed tomography and positron emission tomography with 18-fluorodeoxyglucose did not reveal any para-aortic lymph node recurrence after chemoradiation therapy. Hence, this case was interpreted as a complete response. No recurrence was noted 6 months after the complete response. Chemoradiation therapy with capecitabine/oxaliplatin plus bevacizumab is likely to be effective in treating patients with para-aortic lymph node recurrence.

Omental delivery of prostaglandin E1 effectively increases portal venous blood flow in 66%-hepatectomized rats

Changes in portal venous blood flow (PVF) and systemic arterial blood pressure (SAP) were examined following prostaglandin E1 (PGE) application to the greater omentum and femoral vein in 66%-hepatectomized rats. PVF increased when PGE was administered to the omentum and femoral vein at 7.5 μg/kg per min for 2 min. The magnitude of PVF response due to both administrations was dose-dependent, but the duration of the PVF response in the omental application was longer than that in the femoral administration. SAP was unchanged after omental application, while femoral administration reduced SAP concomitant with an increase in PVF. These results suggest that, in this hepatectomized model, the omentum is a better site for PGE administration than the vein, and that omental PGE delivery is also effective for enhancing PVF without inducing any changes in SAP.

Complete Response of Liver Metastasis of Gastric Cancer Treated by S-1 Chemoradiotherapy: A Case Report

This paper presents a case of suspected liver metastasis of gastric cancer and a virtual complete response to S-1 chemoradiotherapy. A 69-year-old man underwent distal gastrectomy for gastric cancer in 2008. Multiple liver metastases occurred in 2009. He underwent 15 courses of S-1 therapy and radiation therapy (37.5 Gy). Abdominal computed tomography showed virtual complete disappearance of liver metastasis after chemoradiotherapy. Hence, this case was interpreted as a complete response. No sign of recurrence was noted 18 months after complete response was confirmed. S-1 chemoradiotherapy is likely to be effective in treating patients with liver metastases of gastric cancer.