Ryoji Takeda

Treatment of ruptured hepatocellular carcinoma.

AbstractBackground. The problem of whether surgical or conservative treatment is indicated for ruptured hepatocellular carcinoma (HCC) has not been analyzed from the viewpoint of long-term development of hepatitis viral infection from liver fibrosis to liver cirrhosis. Although transcatheter arterial embolization (TAE) for hemostasis followed by two-stage hepatectomy has been established as the best treatment for ruptured HCC, there still remain difficulties in the treatment of some patients. Methods. Twelve patients with ruptured HCC who were surgically or conservatively treated were retrospectively analyzed in terms of modality of treatment, liver function, extension of HCC, complications, survival rate, and cause of death. Results. Tumor rupture can occur either in the early phase or in the terminal phase during the development from liver fibrosis to liver cirrhosis, while tumor rupture occurs at the advanced stage in terms of HCC extension. TAE for emergent hemostasis or prevention of re-bleeding was performed in ten patients, while TAE was contraindicated in one patient and emergent laparotomy for hemostasis was performed in one patient. In four patients, elective extended surgical resection was performed, because liver function was evaluated as clinical stage 1 according to the General rules for the clinical and pathological study of primary liver cancer of the Liver Cancer Study Group of Japan. In seven patients, conservative or medical treat-ment was selected, because liver function was evaluated as poor. The surgically treated group, who could tolerate extensive operation, survived longer than the conservatively treated group. Conclusions. While TAE remains the best method to employ for hemostasis, it still has limitations. Hence, we should be mindful of other possible modalities for hemostasis and their outcomes. Rupture of HCC at an early phase in the development of liver fibrosis is a good indication for elective surgical treatment and should be distinguished from rupture in the terminal phase of liver cirrhosis, which should be treated conservatively. Although elective surgical treatment can be performed in selected patients, tumor size and location of HCC, in addition to liver function, should be taken into consideration.

Tumor thrombi in the portal vein system originating from gastrointestinal tract cancer

Intraluminal tumor thrombus in the portal vein (PV) system originating from gastrointestinal (GI) tract cancer is a rare condition. There are two types of such thrombi, one arising indirectly from metastatic liver cancer and the other directly from the primary lesion. We report here three patients with the direct type and two with the indirect type; i.e., a total of five patients with gastric or large intestinal cancer with PV tumor thrombus. In all patients, the primary lesion was surgically resected; in two patients, the tumor thrombus was easily extirpated by direct opening of the PV. It is noteworthy that a patient whose tumor thrombus could not be treated died of cancer with liver failure, caused by expansive growth of the PV tumor thrombus, 4 months after the finding of the PV thrombus. Because PV tumor thrombus may, possibly, determine the patients length of survival, in addition to causing cancer progression, surgical thrombectomy, combined with resection of the primary cancer and metastatic liver cancer, should be considered for prolongation of survival, if all macroscopic lesions can be controlled and if the tumor thrombus is a synchronous and recent one.

Lymphoepithelial cyst of the pancreas associated with elevated CA 19-9 levels

An extremely rare case of a lymphoepithelial cyst associated with persistent elevation of serum carbohydrate antigen (CA) 19-9 levels is described. A 72-year-old man was incidentally found to have a cystic tumor in the uncus of the pancreas and to have a high serum CA 19-9 level. At 2-year follow up, the tumor size had gradually increased and the high CA 19-9 level persisted. Because the malignant potential of the tumor could not be ruled out, a laparotomy was performed. The tumor was excised from the pancreas. On pathological examination, the tumor was proven to be a lymphoepithelial cyst. After the operation, the patients serum CA 19-9 level decreased to the normal range. Lymphoepithelial cysts of the pancreas are a rare, benign entity. They are true pancreatic cysts, characterized by a mature, keratinizing, squamous lining surrounded by lymphoid tissue. Because the treatment options and the prognosis of these entities are quite different from those of other cystic neoplasms of the pancreas, preoperative differential diagnosis is the main issue. Thus, although they are rare, lymphoepithelial cysts should be considered in the differential diagnosis of cystic tumors of the pancreas.

Perioperative changes in carbonylhemoglobin and methemoglobin during abdominal surgery: Alteration in endogenous generation of carbon monoxide

Abstract Background: Carbon monoxide (CO), which is homologous to nitric oxide (NO) as a monoxide, has been recently studied as a novel gaseous mediator for the maintenance of circulatory homeostasis and as a regulator of organ functions. Abdominal surgery is supposed to modulate the gaseous mediator by the reduction of heme oxygenase (HO) activity or transcriptional regulation of inducible HO. Therefore, we investigated perioperative changes in CO generation during abdominal surgery.

A case of pediatric gastrointestinal stromal tumor of the stomach

A 16-year-old girl with an unremarkable past history presented with sudden dizziness. Patient height was 147 cm, and weight was 43 kg. White blood cell count, red blood cell count, Hgb, Hct, and Plt on blood count were 12600/ μ L, 168 × 10 4 / μ L, 5.3 g/dL, 15.6%, and 14.2 × 10 4 / μ L, respectively. The palpebral conjunctiva exhibited signs of anemia and the patient’s face was pale. Gastrointestinal bleeding was suggested and gastroendoscopic examination was performed. Numerous coagulations with acute bleeding were observed at the central concavity and a small ulcer was seen in the anterior wall of the lower stomach. There were no distinct gastroendoscopic characteristics when compared with other submucosal tumors. Moreover, whole body computed tomography (CT) and magnetic resonance imaging (MRI) showed a large mass in the stomach and revealed no apparent metastasis (Fig. 1). Preoperative differential diagnosis was leiomyosarcoma or malignant lymphoma. A malignant tumor was not considered because the neoplasm was nodular, the surface was smooth, and no typical ulcer formation was observed on gastroendoscopy. The tumor was removed by partial distal gastrectomy through minimal laparotomy and no liver or regional lymph node metastasis was noted. Postoperative course was uneventful, and radiotherapy and chemotherapy were not administered.

Evaluating the significance of HLA class II genotype matching in living-related liver transplantation

To evaluate the clinical significance of HLA class II matching in living-related liver transplantation, the genotypes of HLA class II including DPB1 were determined by the PCR-RFLP (polymerase chain reaction-restriction fragment length polymorphism) method and their matching was compared to the postoperative course. Conventional serotypes included 15.6% and 13.6% errors in DR and DQ, respectively. Among 42 consecutive cases that were followed up over 1 year after transplant, rejection occurred in seven cases. There was no correlation between the matching for each locus and the frequency of rejection episodes. In this study, rejection-free cases were investigated in terms of the potency of immunosuppressive therapy and graft function during 1 year after operation. The doses of tacrolimus in unmatched cases tended to be larger than those in matched cases for every locus except for DQA1. Its trough levels in matched cases were lower than those in unmatched cases, especially at 9-12 months after operation for DRB1 (p < 0.05). The termination of steroid administration tended to be postponed in unmatched cases for every locus. Serum levels of asparatan transaminase, alanine transaminase gamma-glutamyltranspeptidase (gamma-GTP) and total bilirubin were generally lower in matched cases than in unmatched ones for DRB1, DQB1 and DPB1, while in DQA1 the tendency was the opposite, especially total bilirubin and gamma-GTP, which were p < 0.02 and p < 0.05, respectively, at 6 months after operation. Investigation of subclinical immune responses other than rejection episodes showed that DRB1, DQB1 and DPB1 matching had a beneficial effect on graft function, while DQA1 matching seemed to have a varied effect.

Analysis of Deep Posterior Anal Fistulas by Magnetic Resonance Imaging: Site of Primary Abscess and Extension Patterns According to the Primary Abscess Depth

Objectives: The aim of this study was to use magnetic resonance imaging (MRI) to elucidate the site and depth of the primary abscesses associated with deep posterior anal fistulas and their extension patterns. Methods: We analyzed 176 consecutive patients with deep posterior anal fistulas and classified the fistulas according to whether the MRI-detected site of the primary abscess was at a superficial or a deep external anal sphincter (EAS) level. Results: The distance between the anal center and the primary abscess center was significantly shorter than the length of the EAS and radius at an angle of 45°. In addition, deep posterior anal fistulas with primary abscesses located at the deep EAS level penetrated the EAS significantly more laterally and made external openings at a significantly more lateral site than when the primary abscess was located at a superficial EAS level. Conclusions: Primary abscesses associated with deep posterior anal fistulas are located in the posterior intersphincteric space or in the EAS muscle itself, not in Courtneys space, as had previously been claimed.