Primary Cardiac Liposarcoma Causing Cardiac Tamponade: Report of a Case

The intracardiac growth and extension of liposarcoma was observed in a 60-year-old woman. The epicardial tumor was identified to originate from the anterior wall of the right ventricle. She initially showed symptoms associated with cardiac tamponade. A surgical operation was performed but it resulted in incomplete resection due to massive invasion and dissemination. The recurrence of the tumors led to congestive heart failure. Finally, she died of heart failure and liver dysfunction as a result of tumor metastasis and invasion. An autopsy detected the primary cardiac liposarcoma. Only a few cases of cardiogenic liposarcoma have so far been reported. A further elucidation of cardiac liposarcoma could reveal mechanisms of the disease, and thus contribute to development of complementary therapies after surgical intervention.     

Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines

Diagnostic and therapeutic strategies for acute biliary inflammation/infection (acute cholangitis and acute cholecystitis), according to severity grade, have not yet been established in the world. Therefore we formulated flowcharts for the management of acute biliary inflammation/infection in accordance with severity grade. For mild (grade I) acute cholangitis, medical treatment may be sufficient/appropriate. For moderate (grade II) acute cholangitis, early biliary drainage should be performed. For severe (grade III) acute cholangitis, appropriate organ support such as ventilatory/circulatory management is required. After hemodynamic stabilization is achieved, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed. For patients with acute cholangitis of any grade of severity, treatment for the underlying etiology, including endoscopic, percutaneous, or surgical treatment should be performed after the patient's general condition has improved. For patients with mild (grade I) cholecystitis, early laparoscopic cholecystectomy is the preferred treatment. For patients with moderate (grade II) acute cholecystitis, early laparoscopic or open cholecystectomy is preferred. In patients with extensive local inflammation, elective cholecystectomy is recommended after initial management with percutaneous gallbladder drainage and/or cholecystostomy. For the patient with severe (grade III) acute cholecystitis, multiorgan support is a critical part of management. Biliary peritonitis due to perforation of the gallbladder is an indication for urgent cholecystectomy and/or drainage. Delayed elective cholecystectomy may be performed after initial treatment with gallbladder drainage and improvement of the patient's general medical condition.     

Laparoscopy-assisted distal gastrectomy with laparoscopic sentinel lymph node biopsy after endoscopic mucosal resection for early gastric cancer

Background There has been a trend toward minimally invasive treatment of early gastric cancer. We report the preliminary results of laparoscopy-assisted distal gastrectomy with laparoscopic sentinel lymph node biopsy after endoscopic mucosal resection. Methods Six patients underwent laparoscopy-assisted distal gastrectomy after endoscopic mucosal resection between February 2002 and October 2005 at Mie University Hospital. These patients first underwent laparoscopic sentinel lymph node biopsy and then laparoscopy-assisted distal gastrectomy with lymphadenectomy. Results No patient underwent conversion to open surgery during the operation. None of the patients had any postoperative complications. The mean length of postoperative hospital stay was 11.3 days. Sentinel lymph nodes were identified laparoscopically in five patients. There were 20 sentinel and 85 nonsentinel lymph nodes in the six patients. Postoperatively, tissue sections showed that none of the lymph nodes were metastasized. Immunohistochemistry with D2-40 antibody showed that there were normal lymphatics in the submucosal layer with mucosal defects at the endoscopic mucosal resection site. No patients had any tumor recurrence during followup. Conclusions Laparoscopy-assisted distal gastrectomy after endoscopic mucosal resection was a safe and curative procedure. Endoscopic mucosal resection before sentinel lymph node biopsy was acceptable for early gastric cancer.     

Two-stage hepatectomy procedure to treat initially unresectable multiple bilobar colorectal liver metastases: technical aspects

A two-stage hepatectomy procedure is a therapeutic strategy for patients presenting with initially unresectable multiple and bilobar colorectal liver metastases in order to achieve a curative R0 resection. The main goal of this approach is to minimize the risk of postoperative liver failure resulting from a too small remnant liver after completing a curative resection. This procedure combines two sequential liver resections that involve perioperative chemotherapy and portal vein embolization. This article describes our standardized strategy of two-stage hepatectomy combined with portal vein embolization used over the last 15 years and discusses the alternative procedures as well as their respective advantages and drawbacks.     

Management of a lung tumor accompanied by aortic dissection; report of a case

During an annual health check-up, a 75-year-old man was admitted to our hospital due to an abnormal shadow in the left upper lung field. A computed tomography (CT) scan taken at his 1st hospital visit showed a calcified nodule in the left upper lobe and Stanford type A aortic dissection. We could not perform bronchofiberscopy due to the risk associated with the aortic dissection and could not make a diagnosis prior to surgery. Because of the possibility of lung cancer, surgery for the lung tumor and aortic dissection was performed. The pathological diagnosis of the lung tumor was a hematoma. In a case of suspicion of lung cancer along with cardiovascular disease, a surgical diagnosis might be considered.     

A case of Fournier's gangrene reconstructed using a rectus abdominis muscle flap

We encountered a case of Fournier's gangrene complicated with vesicorectocutaneous fistula that was treated with a pedicled rectus abdominis muscle flap (pedicled RA m-c flap). A 75-year-old man was admitted with consciousness disorder and swelling of the scrotum. The patient had noticed swelling of the scrotum 4 days before admission, but he had ignored this condition. The scrotum and the penis appeared necrotic. On the basis of clinical and radiological findings, we diagnosed this condition as Fournier's gangrene. Surgical debridement was performed in conjunction with the use of broad-spectrum antibiotics. After the patient's general condition was improved, the broad defect in the perineal tissue was covered with a pedicled rectus abdominis muscle flap. The flap was successful. In Japan, this is the first case of Fournier's gangrene complicated with vesicorectocutaneous fistula that was treated with a pedicled RA m-c flap. In order to determine whether plastic surgery after debridement shortens the duration of hospitalization, we reviewed the cases of 120 patients with Fournier's gangrene in Japan. We conclude that plastic surgery after debridement does not shorten the duration of hospitalization, however, this procedures is very useful to deep and broad defects by Fournier's gangrene.     

Ruptured thoracic aortic aneurysm complicated by acute aortic dissection and aortic valve regurgitation; report of a case

An 87-year-old man was found loss of consciousness after falling. He was found in a state of shock. Computed tomography showed rupture of aneurysm of the ascending aorta and aortic arch with acute aortic dissection. Echocardiography revealed aortic valve regurgitation and cardiac tamponade. As the result of emergency operation, a large hematoma in the mediastinum and pleural cavity as well as massive serous pericardial effusion were found. The dissection was seen in aneurysm of the ascending aorta and aortic arch with an intimal tear located in the aortic arch. After aortic valve replacement was performed, the ascending aorta and aortic arch were replaced, and reconstruction of 3 cervical vessel branches was performed under deep hypothermic circulatory arrest with selective cerebral perfusion. Despite the complex clinical state and serious condition in the elderly patient, emergency surgery saved the life of the patient without complications.     

Value of Multidetector-row Computed Tomography in Diagnosis of Portal Vein Invasion by Perihilar Cholangiocarcinoma

BACKGROUND: Although knowledge of cancer invasion of the portal bifurcation is vitally important in planning an operation for perihilar cholangiocarcinoma, the diagnostic capability of multidetector-row computed tomography (MDCT) for this purpose has not been assessed. We evaluated how well MDCT could identify cancer invasion of the portal bifurcation by perihilar cholangiocarcinoma. METHODS: Between April 2003 and June 2005, perihilar cholangiocarcinoma was resected in 87 patients, 83 of whom underwent MDCT within 1 month before the surgery. Three-dimensional volume-rendered (3DVR) and multiplanar reformation (MPR) images were examined for evidence of portal vein invasion. Agreement with intraoperative and pathologic findings was assessed. Portal bifurcation findings by 3DVR and MPR were classified into no portal vein stenosis, unilateral stenosis, or more extensive stenosis, and also into tumor contact with the bifurcation in no, one of two, or two projections. RESULTS: For macroscopic portal vein invasion, sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were 81.5, 91.1, 81.5, 91.1, and 88.0% in 3D portography and 96.3, 92.6, 86.7, 98.1, and 94.0% in MPR, respectively. Findings by both 3DVR and MPR were significantly correlated with depth of cancer invasion (p < 0.001). CONCLUSION: MDCT is useful in assessing cancer invasion of the portal vein bifurcation by perihilar cholangiocarcinoma.     

Rapamycin, but not cyclosporine or FK506, alters natural killer cell function

Infiltration of natural killer (NK) cells into solid organ allografts is observed in clinical and experimental transplantation. Studies suggest a role for NK cells in acute and chronic rejection of solid organ allografts; however, the effects of immunosuppressive agents on NK cells are not clearly established. Rat NK cell lines were analyzed for proliferation and cytotoxicity in the presence of cyclosporine, FK506, or rapamycin. Lewis recipients of DA liver allografts received immunosuppressive agents after transplantation. NK cells demonstrated robust function both in the absence and presence of cyclosporine and FK506. In contrast, rapamycin significantly inhibited proliferation and cytotoxicity of NK cells. NK cell numbers remained stable in graft recipients treated with cyclosporine and FK506, whereas there was a significant decrease in NK cells in rapamycin-treated recipients. These data indicate that immunosuppressive drugs have differential effects on NK cell function that may impact the immune response of transplant recipients.     

Flowcharts for the management of biliary tract and ampullary carcinomas

No strategies for the diagnosis and treatment of biliary tract carcinoma have been clearly described. We developed flowcharts for the diagnosis and treatment of biliary tract carcinoma on the basis of the best clinical evidence. Risk factors for bile duct carcinoma are a dilated type of pancreaticobiliary maljunction (PBM) and primary sclerosing cholangitis. A nondilated type of PBM is a risk factor for gallbladder carcinoma. Symptoms that may indicate biliary tract carcinoma are jaundice and pain in the upper right area of the abdomen. The first step of diagnosis is to carry out blood biochemistry tests and ultrasonography (US) of the abdomen. The second step of diagnosis is to find the local extension of the carcinoma by means of computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP). Because resection is the only way to completely cure biliary tract carcinoma, the indications for resection are determined first. In patients with resectable disease, the indications for biliary drainage or portal vein embolization (PVE) are checked. In those with nonresectable disease, biliary stenting, chemotherapy, radiotherapy, and/or best supportive care is selected.