Nozomi Shinozuka

Autologous blood transfusion in patients with hepatocellular carcinoma undergoing hepatectomy

BACKGROUND Homologous blood transfusion (HBT) has the risk of an immunosuppressive effect and may adversely affect the prognosis of patients with carcinomas. Autologous blood transfusion (ABT) has not yet become a standard procedure in gastroenteric cancer surgery. We investigated the usefulness and problems of ABT combined with the use of recombinant human erythropoietin (rh-EPO). METHODS An evaluation of autologous blood transfusion (ABT) combined with recombinant human erythropoietin (rh-EPO) treatment was conducted in 46 patients with hepatocellular carcinoma undergoing hepatectomy. Preoperative autologous blood donation (ABD) was accomplished for 25 of the 46 patients. The preoperative changes in hemoglobin and hematocrit in relation to route of administration of erythropoietin were studied. In addition, intraoperative blood requirements and the postoperative complications for patients who predonated were compared with those of patients who underwent surgery without autologous predonation. RESULTS The proportion of patients not requiring additional homologous blood transfusions (HBT) during operation was significantly higher in the ABD group than in the non-ABD group (88% versus 38%). The incidence of postoperative complications was significantly higher in patients receiving HBT than in nontransfused patients and in those receiving ABT. CONCLUSIONS Preoperative autologous blood donation in combination with rh-EPO therapy markedly reduced the requirement for homologous blood transfusion during surgery in patients with hepatocellular carcinoma having hepatectomy.

α-fetoprotein–producing Clear Cell Carcinoma of the Extrahepatic Bile Ducts

A 79-year-old woman visiting our hospital with chief complaints of epigastric pain and jaundice was emergently admitted. Her alpha-fetoprotein (AFP) level was as high as 2265 ng/mL at admission. Her abdominal computed tomography scan revealed dilation of the intrahepatic bile duct and a tumorlike lesion protruding into the cystic duct and gallbladder from the junction between the middle portion of the bile duct and the right and left hepatic ducts. Surgery revealed a tumor extending from the extrahepatic bile duct (EHBD) to the cystic duct, with no intrahepatic tumor components. The tumor was histologically diagnosed as an AFP-producing cholangiocarcinoma of the clear cell type, originating from the EHBD. None of the previously reported cholangiocarcinomas of the AFP-producing clear cell type have been confined to the EHBD or have been resectable in a curative manner without hepatectomy.

Total body cooling using cardiopulmonary bypass for procurement from non-heart-beating donors

THE organ shortage in transplantation is a big problem in most countries. Japan is no exception; indeed, it is a most serious situation. A law governing brain death was recently legislated in Japan. Until then only non-heartbeating donors were the source for cadaveric kidney transplantation. Many approaches have been attempted in order to obtain warm ischemic organs of good quality. We have been focusing the procurement method on reducing the ischemic damage sustained during warm ischemia. Warm ischemic organs usually lose vascular tone, leading to vascular spasm. Therefore, conventional cooling methods would fail to cool the organs efficiently. We utilized a cardiopulmonary bypass system for total body cooling in hopes of ameliorating the warm ischemic damage by supplying oxygenated blood to the organs.

Postoperative recurrence and risk factors of colorectal cancer perforation

PurposeThe common causes of colorectal perforation are benign. However, perforated colorectal cancer confers a risk of recurrence in the long term because of the malignant nature of the disease. In addition, the recurrence rate can also increase because of dissemination of cancer cells, reduced extent of lymph node dissection to prioritize saving life, and other reasons.MethodsWe evaluated the clinical features and postoperative recurrence in patients with perforated colorectal cancer who developed general peritonitis and underwent emergency surgery during a 7-year period between April 2007 and March 2014.ResultsDuring the study period, 44 patients had colorectal cancer perforation. The cancer sites were the ascending colon in 6 patients, transverse colon in 1, descending colon in 4, sigmoid colon in 15, and rectum in 18. The disease stage was stage II in 18 patients, stage III in 15, and stage IV in 7. Among 22 patients who could be followed up, 8 had postoperative recurrence. The recurrence rates were 18.2% for stage II cancer and 54.5% for stage III. Postoperative recurrence was more likely to occur in the patients positive for lymph node metastasis, those with poorly differentiated adenocarcinoma, those with T4 cancer, and those who did not receive postoperative adjuvant chemotherapy.ConclusionThe recurrence rate was higher in the patients with perforated colorectal cancer than in those who underwent surgery for common colorectal cancer. The prognosis can be expected to improve by performing standard surgical procedures, to the maximum extent possible, followed by postoperative adjuvant chemotherapy.

A comparative study on the short-term clinical outcomes of laparoscopic versus open Hartmann's procedure for high risk patients in colorectal cancer.

BACKGROUND/AIMS Patients with severe co-morbidities and oncological conditions would not be denied a reconstruction of anastomosis and Hartmanns procedure would be undertaken. The aim of this study is to examine the feasibility and safety of laparoscopic Hartmanns procedure compared to open Hartmanns procedure for high risk patients in colorectal cancer. METHODOLOGY Nine hundred and eighty five primary colorectal cancer resections were performed from April 2007 to December 2010. Thirty six patients (3.6%) who underwent Hartmanns procedure by the same surgical team were investigated retrospectively. RESULTS Twenty six patients (72%) in the open surgery (OS) and 10 patients (28%) in the laparoscopic surgery (LS) were undertaken Hartmanns procedure. The reason of selected Hartmanns procedure was defined as high risk with severe co-morbidities (OS 8: LS 8, n=16), oncological conditions (OS 14: LS 2, n=16), urgent situations (OS 4, n=4). The mean operation time was not significantly different (p=0.504). The median blood loss count was significantly different between both groups (OS 327.5g vs. LS 16.5g; p=0.0001). The incidence of postoperative complications was similar (OS 38% vs. LS 40%; p=0.763). The median postoperative hospital stay was not significantly different (OS 10.5 vs. LS 12; p=0.216). CONCLUSIONS Laparoscopic Hartmanns procedure is feasible and safe with a low invasiveness for high risk patients with colorectal cancer.

Mesh penetrating the cecum and bladder following inguinal hernia surgery: a case report

BackgroundTension-free repair using mesh is a common inguinal hernia surgical procedure. However, various complications such as mesh-related infection and recurrence may develop as a result. Moreover, although rare, there are also reports of intestinal obstruction caused by adhesion of the mesh to the intestinal wall and cases of mesh migration into various organs. Here, we report our experience with a patient in whom mesh extraction was performed due to migration of mesh into the intestinal tract following inguinal hernia surgery and formation of a fistula with the bladder.Case presentationOur patient was a 63-year-old Japanese man who had a history of operative treatment for right inguinal hernia during early childhood. Because a relapse subsequently occurred, he was diagnosed as having recurrent right inguinal hernia at the age of 56 years for which operative treatment (the Kugel method) was performed. He presented to our hospital 6 years later with the chief complaint of lower abdominal pain. Computed tomography findings revealed a mass shadow in contact with his bladder and cecal walls, and enteric bacteria were detected in his urine. Furthermore, because lower gastrointestinal endoscopic findings confirmed mesh in the cecum, we performed operative treatment. The mesh had migrated into the cecum and a fistula with his bladder had formed. We removed the mesh through ileocecal resection and partial cystectomy.ConclusionsIt appeared that a peritoneal defect occurred when the mesh was placed, allowing the mesh to migrate into our patient’s intestinal tract. Because contact between the mesh and the cecum resulted in inflammation, a fistula formed in his bladder. It is important to completely close the peritoneum when placing the mesh.

Lymphatic mapping and lymphatic endothelial cell isolation in colorectal cancer patients

Background:  Sentinel lymph node (SLN) biopsy has already been established as a common procedure with malignant lymphoma and breast cancer. In colorectal cancer, however, the application of the SLN theory remains uncommon and its clinical significance is also unclear. In addition, the characteristics of the lymphatic vessels that connect SLNs or the lymphatic endothelial cells have been unclear. Our purpose is to determine the feasibility and accuracy of SLN mapping by intraoperative subserosal dye injection and to develop a novel method for the isolation of anatomically defined lymphatic endothelial cells.

Hemodynamic changes of azygos venous flow after ligation of the azygos arch

The uppermost portion or arch of the azygos vein is frequently ligated and divided in thoracic surgery. The hemodynamic effects arising from this proce dure have not, however, been described previously. The authors assessed such effects by using transesophageal real-time two-dimensional Doppler echography (TE2DD). Nine patients, whose azygos arch had been ligated and divided in the course of surgery for lung cancer, were examined. The intervals between the prior operation and the examination with TE2DD ranged from one to fifty months. By use of a convex array transducer with a frequency of 7.5 MHz, the hemodynamics of both the azygos vein and the intercostal veins, which join the former, were assessed. The esophagopetal portion of the azygos vein could be visualized in color in 6 of 9 cases. In all these 6 cases, the flow direction of the azygos vein was reversed and directed caudally. Blood flow in both the azygos vein and the intercostal veins is normally pulsatile. After ligation, however, it had become constant in 3 of 5 cases analyzed by pulsed Doppler spectrum. The value of mean flow velocity in the azygos vein (9 ± 5 cm/sec) was significantly (p < 0.05) smaller than that of the control group (15 ±5 cm/sec).

Effects of intraaortic balloon pumping on portal venous flow : assessment with color doppler echography

The effects of intraaortic balloon pumping (IABP) on portal venous flow were assessed using color Doppler echography. A total of 23 heart failure patients treated with IABP were assessed. Balloon inflation was timed to occur with every other cardiac contraction. The maximum, minimum, and mean flow velocity (Vmax, Vmin and Vmean, respectively) in the right portal vein were measured with the IABP ON and OFF, and the values compared. The Vmin with IABP ON and OFF was the same (11 ±5 cm/sec), whereas the difference between Vmax and Vmean was small for each patient. The velocities measured with IABP ON were larger than or equal to those with IABP OFF in all cases, however, except one. Thus, Vmax (22±8 cm/sec) and Vmean (17±6 cm/sec) with IABP ON were significantly larger (p 0.01) than those with IABP OFF (20±7 cm/sec and 16±6 cm/sec, respectively). The flow pattern of the portal vein was characteristically pulsatile either with IABP ON or OFF in most cases.