Takamitsu Inokuma

Hemophagocytic syndrome after liver transplantation: Report of two cases

We report two cases of hemophagocytic syndrome (HPS), a rare but fatal complication after living-donor liver transplantation (LDLT). Despite their recovery from pancytopenia following treatment with steroid pulse therapy, granulocyte stimulating factor, and intravenous γ-globulin, both patients died. The outcomes reported in cases published in English are devastating, with only 4 survivors among the total 14 patients including ours. Pancytopenia is frequently recognized postoperatively in liver transplant recipients, although its cause is difficult to establish. When pancytopenia accompanying persistent high fever is recognized in LDLT recipients, HPS should be suspected and bone marrow aspiration performed as promptly as possible because of the poor prognosis of this syndrome. There is still no optimal treatment for HPS after liver transplantation.

Suppression of reactive oxygen species develops lymph node metastasis in colorectal cancer.

BACKGROUND/AIMS Recent evidence indicates that reactive oxygen species (ROS) can induce a wide type of cellular responses from proliferation to senescence and cell death. ROS may not be an absolute carcinogenic factor or cancer suppressor. The aim of this study was to assess the biological paradox of ROS in colorectal cancer cells. METHODOLOGY Blood specimens were obtained from the drainage vein of the tumor during operation in 135 patients with colorectal cancer. Serum ROS levels were measured using the derivatives of reactive oxygen metabolites (d-ROM) test. RESULTS Serum ROS levels increased significantly in tumor size larger than 40mm (p<0.01). On the other hand, serum ROS levels decreased significantly in patients with lymph node metastasis (p<0.01). Multiple linear regression models showed a significant association of serum ROS levels with serum carcinoembryonic antigen (CEA) levels (p<0.01) and lymph node metastasis (p=0.026). CONCLUSIONS In colorectal cancer cells, the increase of intracellular ROS is first associated with cell growth and invasion. However, a further increase inhibits cancer cell proliferation, whereas any decrease in ROS concentration needs to stimulate lymph node metastasis. Thus, a precise understanding how ROS are generated and involved in lymph node metastasis will help us to design better therapeutic strategies.

Curcumin improves the survival rate after a massive hepatectomy in rats.

BACKGROUND/AIMS Curcumin possesses anti-inflammatory and antioxidant effects. Curcumin pretreatment provided a hepatoprotective effect in rat models of chemically-induced hepatotoxicities and ischemia/reperfusion injuries. In this study, we examined whether curcumin could improve the survival rate of rats undergoing a 90% hepatectomy. METHODOLOGY Rats were administered 340 mg/kg oral curcumin formulated with phosphatidylcholine (curcumin group) or vehicle (control group) for 7 consecutive days and 2 hours prior to the massive hepatectomy. RESULTS Six of the 13 rats pretreated with curcumin survived, whereas all 13 rats pretreated with vehicle died within day 2 following a massive hepatectomy. A histological examination showed the lobular structure to be disturbed in the rats pretreated with vehicle, whereas the hepatic lobular structure remained relatively stable without necrosis in the rats pretreated with curcumin. The contents of heme oxygenase-1 (HO-1) protein in the control group were low in the preoperative phase. In contrast, the levels of HO-1 protein in the curcumin group were high at the preoperative phase, and thereafter remained at high levels until day 7 following surgery. CONCLUSIONS Our results suggest that curcumin improves the survival rate by increasing the antioxidant activity in rats after a massive hepatectomy.

The serum level of carcinoembryonic antigen in drainage venous blood is not a sensitive predictor of metachronous hepatic metastasis for patients with colorectal cancer

PurposeTo establish whether the serum levels of carcinoembryonic antigen (CEA) in drainage venous blood (d-CEA) is a better predictor of prognosis or survival than the preoperative CEA level in peripheral venous blood (p-CEA), and how these two CEA levels compare as predictive factors for metachronous hepatic metastasis.MethodsWe examined specimens of peripheral and drainage venous blood from 119 patients with colorectal cancer.ResultsThere was a strong positive correlation between p-CEA and d-CEA levels. The 5-year survival rates were 81.5% and 80.2% for patients with normal p-CEA and d-CEA levels (≤5 ng/ml), respectively, and 68.4% and 71.1% for those with abnormal p-CEA and d-CEA levels (>5 ng/ml). The p-CEA and d-CEA levels were both normal in seven of ten patients with metachronous hepatic metastasis. The CEA gradient between the d-CEA and p-CEA levels (d-p CEA gradient) was not a significant predictive factor for hepatic metastases.ConclusionsThere was virtually no change between preoperative p-CEA and d-CEA levels. These findings suggest that the d-CEA level is not a predictor for metachronous hepatic metastasis and that measuring p-CEA levels is sufficient in the surveillance of colorectal cancer.

Portable system for monitoring of regional cerebral oxygen saturation during prehospital cardiopulmonary resuscitation: a pilot study

We aimed to create a system for monitoring of regional cerebral oxygen saturation (rSO2) in patients with prehospital cardiopulmonary arrest and clarify the changes in rSO2 during cardiopulmonary resuscitation.

Changes in quality of life after hepatectomy and living donor liver transplantation

BACKGROUND/AIMS Quality of life has become important as an outcome in addition to conventional outcomes such as disease-free and overall survival. In this study, we compared the fluctuations of quality of life after hepatectomy and living donor liver transplantation. METHODOLOGY Thirteen adult patients undergoing hepatectomy and 7 with living donor liver transplantation were enrolled. The SF-36, which can objectively measure health-related generic physical and mental quality of life, was completed before surgery and at 3, 6, 9 and 12 months after surgery. RESULTS Before surgery, the scores of 7 out of 8 domains in SF36 were significantly lower in the transplantation group than in the hepatectomy group. After hepatectomy, quality of life dropped temporarily and subsequently gradually recovered toward the baseline, while after transplantation, quality of life, especially mental function, tended to be improved beyond the baseline. Consequently, the quality of life of the transplantation patients became comparable to that of the hepatectomy patients 12 months after surgery. CONCLUSIONS Living donor liver transplantation was demonstrated to be a sensible therapeutic intervention for liver failure and malignances from the point of view of improvement in physical and mental quality of life.

Management of cytomegalovirus infection after living donor liver transplantation.

BACKGROUND/AIMS Few studies on Cytomegalovirus (CMV) infection in adult-to-adult living donor liver transplantation (LDLT) have been reported. The aim of this study was to analyze the incidence, risk factors and management of CMV infection after LDLT. METHODOLOGY Retrospective analysis was performed with 72 consecutive adult cases. RESULTS CMV antigenemia was demonstrated in 31 (43.1%) patients and 9 patients (12.5%) manifested fever. Twelve patients were treated with intravenous ganciclovir (GCV) injection. There was improvement in 10 patients; foscanet concomitant with CMV-IG was administered in one patient who had an adverse effect resulting in improvement and another one resulted in death from sepsis. Twelve patients were given oral valganciclovir (VGCV) and all showed improvement. ABO incompatible transplantation was associated with CMV infection after LDLT in both the univariate (p=0.005) and multivariate analyses (p=0.04). After discharge 12 out of 63 patients (19%) suffered from CMV infection and all of them were taking steroid. CONCLUSIONS ABO incompatible transplantation was demonstrated as a risk factor for CMV infection during hospitalization. After discharge immunosuppressive status seemed to be more essential as a predictor for CMV infection. Routine examination to detect CMV antigenemia is needed especially in patients with potentially over-immunosuppressive conditions in out-patient clinics.

An adult case of laryngopharyngeal burn by drinking hot water

A 61‐year‐old man who was hospitalized with schizophrenia in a psychiatric hospital drank hot water estimated to be 90°C. Eight hours after injury, laryngopharynx edema gradually progressed, and his breathing deteriorated. Upon arrival at our emergency room, we secured his respiratory tract by nasal intubation under a bronchoscope.

Two‐stage explantation of a cirrhotic liver for liver transplantation in a patient with a coronary bypass using a right gastroepiploic artery

The right gastroepiploic artery (RGEA) has been considered a fair alternative choice for a coronary bypass graft. However, after such nonanatomical anastomosis, it is difficult to plan abdominal surgery without endangering the critical arterial supply. To date, gastrectomies and pancreatoduodenectomies have been reported in patients with RGEA grafts for coronary bypass. We recently performed living donor liver transplantation (LDLT) in a patient who had previously undergone coronary bypass surgery using RGEA 3 years before the LDLT. This is the first case of LDLT after coronary bypass using RGEA. We report our two-stage explantation of the cirrhotic liver without any injury to the RGEA. The patient was a 63-year-old man suffering from end-stage liver failure and persistent cholangitis due to primary sclerosing cholangitis in May 2007. LDLT was indicated, and preoperative angio-computed tomography was performed and revealed that the patent RGEA graft was located on the left lobe of the cirrhotic liver (Fig. 1A). The LDLT was scheduled on May 28, 2007, with the attendance of a cardiac surgeon and full monitoring of cardiac function, including transesophageal ultrasound. Laparotomy showed that the RGEA was on the left lobe of the cirrhotic liver (Fig. 1B). In order to liberate the RGEA, the left lateral segmentectomy was performed first with the Cavitron ultrasonic surgical aspirator system (CUSA; Valley-Lab, Boulder, CO) and saline-linked cautery (Dissecting Sealer DS 3.0, Tissue Link Medical, Inc., Dover, NH) with minimal blood loss (Fig. 1B,C). Subsequently, the remnant right lobe of the liver was explanted without a spastic event of the RGEA being caused; a left lobe graft from a living donor was then implanted. The RGEA was placed on the dorsal side of the graft because this was the natural position of the RGEA (Fig. 1D). No cardiac event occurred throughout the LDLT, with total blood loss of 1900 g during a total operative time of 1015 minutes. The patient’s postoperative course was uneventful, and he was discharged from our hospital on the thirty-first day after the LDLT. As of this writing, he has been doing well for 8 months since the LDLT. Performing LDLT in patients after previous abdominal surgery is a therapeutic challenge. In particular, the gastroepiploic artery used for coronary arterial bypass is a cumbersome entity because damage to the artery can cause significant consequences for the patient, including cardiac infarction. We performed two-stage explantation of the liver because it was impossible to mobilize the cirrhotic liver with the RGEA in place as the RGEA was present on the left lobe of the liver. After we recognized the situation through a preoperative three-dimensional recon-

Novel screening criteria for post-traumatic venous thromboembolism by using D-dimer

Because severe trauma patients frequently manifest coagulopathy, it is extremely important to detect venous thromboembolism (VTE) in the acute phase. However, no reference value for D‐dimer in post‐traumatic VTE has been reported given the substantial increase in its levels after injury. Therefore, this study evaluates the ability of our screening criteria using D‐dimer to detect VTE in severe trauma patients.