Takaoki Watanabe

Successful resection of metachronous liver metastasis from α-fetoprotein-producing gastric cancer: Report of a case

We present herein the case of a 68-year-old man in whom metachronous liver metastasis from an α-fetoprotein (AFP)-producing gastric cancer was successfully treated. The patient initially underwent a distal gastrectomy for an AFPproducing gastric cancer on January 30, 1997, following which the serum AFP level which had been 228 ng/ml prior to surgery decreased to 30 ng/ml. However, 7 months after surgery, follow-up examination revealed an abnormal elevation of the serum AFP level up to 301 ng/ml, and a liver tumor was subsequently detected at segment 8 (S8) by abdominal ultrasonography. There was no evidence of hepatitis B or C virus infections. After various investigations, he was diagnosed to have liver metastases in S6 and S8, from the AFP-producing gastric cancer, and a partial hepatectomy of S6 and S8 was performed. His postoperative course was uneventful and he was discharged on postoperative day 26. Thereafter, his serum AFP levels decreased and have remained within normal limits for 12 months since his operation. To the best of our knowledge, this is the first case of successful resection of metachronous liver metastasis from an AFP-producing gastric cancer.

Management of major portosystemic shunting in small-for-size adult living-related donor liver transplantation with a left-sided graft liver

PurposeWe investigated the mechanisms of small-for-size graft syndrome by time-lag ligation, a novel approach to treating major portosystemic shunts in small-for-size adult living-related donor liver transplantation (LRDLT) using left-sided graft liver.MethodsFive patients with end-stage liver failure and major splenorenal shunting underwent LRDLT using left lobe grafts. The average graft volume to recipient body weight (GV/RBW) ratio was 0.68 ± 0.14. Two patients underwent time-lag ligation of their splenorenal (SR) shunts on postoperative days (PODs) 8 and 14, respectively. The shunts of the other three patients were untreated.ResultsThe portal pressures in the first patient who underwent time-lag ligation rose above 300 mmH2O and remained there for 2 weeks. Thus, we ligated the SR shunt in the second patient on POD 14, resulting in an increase from 177 mmH2O to 258 mmH2O, but it decreased again thereafter. In the other three patients, the SR shunt was not ligated because portal blood flow volumes remained sufficient. Total bilirubin levels in the first time-lag ligation patient rose to 16 mg/dl, paralleling the rise in portal pressures. Although they increased after ligation in the second patient, they did not exceed 10 mg/dl.ConclusionsWe recommend time-lag ligation if portal venous blood flow decreases in the early post-transplant period, but not until at least 2 weeks after transplantation. If the portal venous blood flow does not decrease, early postoperative ligation is unnecessary. If there are no major portosystemic shunts, making a portosystemic shunt might decompress excessive portal hypertension. With donor safety priority in LRDLT, novel approaches must be developed to enable the use of smaller donor grafts. We describe a potential means of using left lobe grafts in adult LRDLT.

Splenic-intrahepatic left portal shunt in an adult patient with extrahepatic portal vein obstruction without recurrence after pancreaticoduodenectomy

In the last decade, a superior mesenteric-intrahepatic left portal shunt (Rex shunt) has been reported for successful management of extrahepatic portal vein obstruction in children. However, in adults, a mesocaval shunt has been generally performed for the surgical management of extrahepatic portal vein obstruction because of the complexity of the underlying disease and the difficulty of the superior mesenteric-intrahepatic left portal shunt. We herein report an adult patient who was successfully treated by splenic-intrahepatic left portal shunt with an artificial graft (6-mm polytetrafluoroethylene) for complete obstruction of the extrahepatic portal vein following pancreaticoduodenectomy. The shunt procedure not only relieved portal hypertension but also restored hepatic portal flow. In the near future, the Rex shunt should be considered for a beneficial management of extrahepatic portal vein obstruction, even in adults.

Thrombotic Microangiopathy After ABO-Incompatible Living Donor Liver Transplantation: A Case Report

Thrombotic microangiopathy (TMA) has rarely been reported in the setting of liver transplantation. Herein we have reported a successful case of TMA after ABO-incompatible living donor liver transplantation (LDLT) treated with plasma exchange and high-dose intravenous gamma-globulin infusion. A 50-year-old woman was diagnosed with hepatitis C virus-related cirrhosis. We performed an ABO-incompatible LDLT (group B to O) with preoperative plasma exchange to reduce the anti-B hemagglutinin titers to 1:8. The immunosuppressants consisted of tacrolimus, mycophenolate mofetil, and steroid. On postoperative day (POD) 8, her anti-B hemagglutinin titer suddenly increased to 1:64. The serum lactate dehydrogenase (LDH) level was grossly elevated (1518 IU/L). On POD 13, we suspected infection of an intra-abdominal hematoma (Serratia marcescens) which was drained surgically. On day 5 after the reoperation, thrombocytopenia developed with a platelet count of 3 x 10(4)/mm3. A peripheral blood film showed severe red blood cell (RBC) fragmentation. Thus, we made a clinical diagnosis of TMA and reduced the tacrolimus dose. We started intensive daily plasma exchange (4 L/d) with fresh frozen plasma and high-dose intravenous gamma-globulin infusions. One week thereafter, thrombocytopenia improved with reduced transfusion requirements. The peripheral blood film showed normal RBC morphology. The serum LDH returned to baseline levels. Four factors were considered to have caused TMA in this case: the prescription of tacrolimus, ABO-incompatible liver transplantation, bacterial infection, and surgical stress. These factors may have all contributed by causing significant endothelial injury and TMA.

A Case of Idiopathic Stomal Fistula Developing in a Very Elderly Patient 23 Years after Miles' Operation

症例は90歳の女性で,23年前に腹会陰式直腸切断術の手術歴があった.認知症と廃用 症候群で他院入院中に不明熱と人工肛門パウチ漏れが続き,原因検索目的に当院を紹介 受診した.人工肛門周囲に瘻孔を認めたほか,腹部CT検査で人工肛門周囲皮下膿瘍と 挙上腸管狭窄を認め,ドレナージシートン術を施行した.術後腸管造影検査で憩室は認 めず,特発性人工肛門皮膚瘻孔と診断した.ブジーするも狭窄部は拡張せず,瘻孔が排 泄口となり,頻回のパウチ漏れが起きた.単品系装具を瘻孔ごと覆い 2 ‐ 3 日おきに交 換して人工肛門管理が向上し,術後第28病日に前医へ転院した.転院後,膿瘍腔が縮小 しチューブが外れたが,瘻孔は排泄口として機能しており経過観察した.術後10カ月経 過し,トラブルなく生存している.日常生活動作の低い超高齢者で特発性人工肛門皮膚 瘻孔に対し,ドレナージシートン術で人工肛門再造設を回避できた症例を経験したので 報告する.