Management of bleeding and artificial gastric ulcers associated with endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD), an endoscopic procedure for the treatment of gastric epithelial neoplasia without lymph node metastases, spread rapidly, primarily in Japan, starting in the late 1990s. ESD enables en bloc resection of lesions that are difficult to resect using conventional endoscopic mucosal resection (EMR). However, in comparison to EMR, ESD requires a high level of endoscopic competence and a longer resection time. Thus, ESD is associated with a higher risk of adverse events, including intraoperative and postoperative bleeding and gastrointestinal perforation. In particular, because of a higher incidence of intraoperative bleeding with mucosal incision and submucosal dissection, which are distinctive endoscopic procedures in ESD, a strategy for endoscopic hemostasis, mainly by thermo-coagulation hemostasis using hemostatic forceps, is important. In addition, because of iatrogenic artificial ulcers that always form after ESD, endoscopic hemostasis and appropriate pharma-cotherapy during the healing process are essential.     

Assessment for the minimal invasiveness of laparoscopic liver resection by interleukin-6 and thrombospondin-1

BACKGROUNDLaparoscopic surgery has been introduced as a minimally invasive technique for the treatment of various field. However, there are few reports that have scientifically investigated the minimally invasive nature of laparoscopic liver resection (LLR).AIMTo investigate whether LLR is scientifically less invasive than open liver resection.METHODSDuring December 2011 to April 2015, blood samples were obtained from 30 patients who treated with laparoscopic (n = 10, 33%) or open (n = 20, 67%) partial liver resection for liver tumor. The levels of serum interleukin-6 (IL-6) and plasma thrombospondin-1 (TSP-1) were measured using ELISA kit at four time points including preoperative, immediate after operation, postoperative day 1 (POD1) and POD3. Then, we investigated the impact of the operative approaches during partial hepatectomy on the clinical time course including IL-6 and TSP-1.RESULTSSerum level of IL-6 on POD1 in laparoscopic hepatectomy was significantly lower than those in open hepatectomy (8.7 vs 30.3 pg/mL, respectively) (P = 0.003). Plasma level of TSP-1 on POD3 in laparoscopic hepatectomy was significantly higher than those in open hepatectomy (1704.0 vs 548.3 ng/mL, respectively) (P = 0.009), and have already recovered to preoperative level in laparoscopic approach. In patients with higher IL-6 Levels on POD1, plasma level of TSP-1 on POD3 was significantly lower than those in patients with lower IL-6 Levels on POD1. Multivariate analysis showed that open approach was the only independent factor related to higher level of IL-6 on POD1 [odds ratio (OR), 7.48; 95% confidence interval (CI): 1.28-63.3; P = 0.02]. Furthermore, the higher level of serum IL-6 on POD1 was significantly associated with lower level of plasm TSP-1 on POD3 (OR, 5.32; 95%CI: 1.08-32.2; P = 0.04) in multivariate analysis. CONCLUSIONIn partial hepatectomy, laparoscopic approach might be minimally invasive surgery with less IL-6 production compared to open approach.     

Male-specific Association between Iron and Lipid Metabolism Changes and Erythroferrone after Hepatitis C Virus Eradication

Objective Hepatitis C virus (HCV) eradication is associated with decreased serum ferritin and increased serum low-density lipoprotein-cholesterol (LDL-C) levels, although the mechanisms underlying these changes remain unclear. This study aimed to identify the mechanisms underlying the changes in iron and lipid metabolism after HCV eradication. Methods We retrospectively investigated iron and lipid metabolism changes in 22 patients with chronic hepatitis or compensated liver cirrhosis with HCV genotype 1b infection after HCV eradication. We measured the serum erythroferrone (ERFE) levels to assess the association with these metabolic changes. Patients were administered ledipasvir 90 mg and sofosbuvir 400 mg once daily for 12 weeks and were observed for 12 more weeks to evaluate the sustained virological response. Results Half of the patients were men. At baseline, the serum ferritin and ERFE levels were elevated, while the serum LDL-C levels were within the normal range. All patients achieved a sustained virological response at 24 weeks; furthermore, the serum ferritin and ERFE levels were significantly decreased, and the serum LDL-C levels were significantly increased at 24 weeks from baseline (p＜0.001, all). In men, a decrease in serum ERFE levels was correlated with changes in the serum ferritin and LDL-C levels (r=0.78, p＜0.01; r=-0.76, p＜0.01, respectively). In addition, a decrease in the serum ferritin levels was correlated with an increase in the serum LDL-C levels (r=-0.89, p＜0.001). These correlations were not observed in women. Conclusion Our results suggest a possible association between iron and lipid metabolism changes and the involvement of ERFE after HCV eradication in men as well as potential sex-related differences.     

An Autopsy Case of Ki-1 Lymphoma Associated with Hepatic Failure

A 62-year-old man was admitted to our hospital because of severe jaundice and fever. Physical examination demonstrated hepatosplenomegaly. The laboratory data revealed elevated serum bilirubin, alkaline phosphatase, lactate dehydrogenase, aspartate aminotransferase and alanine aminotransferase, and the reduced hepaplastin test (Normotest). Computed tomography showed hepatosplenomegaly and swelling of the paraaortic lymph nodes. Although he was treated with antibiotics and steroids, he died of hepatic failure 22 days after admission. At autopsy, his liver weighed 1910 grams, and a histological examination of the liver revealed marked infiltration of CD30 (Ki-1) positive lymphoma cells. He was diagnosed as having non-Hodgkin lymphoma, large cell anaplastic type, Ki-1 lymphoma. We herein report our findings of this very rare case of Ki-1 lymphoma associated with hepatic failure.     

Functional immaturity of cord blood monocytes as detected by impaired response to hepatocyte growth factor

BACKGROUND: Monocytes as antigen-presenting cells play an important role in host defense and transplantation. However, there are little reports on cord blood monocytes, and the role of monocytes in cord blood transplantation is largely unknown. METHODS AND RESULTS: There are several cytokines affecting monocyte function. These include interferon-gamma, interleukin-4, interleukin-10, granulocyte macrophage-colony stimulating factor and hepatocyte growth factor (HGF). We investigated the effect of these cytokines on antigen-presenting capacity (APC) of cord and adult blood monocytes. Using either mononuclear cells or purified CD4+ T cells as responder cells, HGF enhanced APC of adult monocytes most effectively among these cytokines. In contrast, cord blood monocytes failed to respond to HGF. As HLA, costimulatory and adhesion molecules may affect APC function, we examined these antigens of monocytes following HGF stimulation. The HGF upregulated integrin alpha5 subunit (CD49e) and intercellular adhesion molecule-1 (CD54) was expressed in adult blood monocytes, but not in cord blood. In kinetic studies, HGF downregulated c-met protein/HGF receptor expression of adult monocytes in lower concentrations and at shorter incubation time as compared with that of cord blood. CONCLUSIONS: The results suggest that impaired response of cord blood monocytes to HGF may be responsible, in large part, for their functional immaturity.     

Erythropoietic protoporphyria with fatal liver failure

A 33-year-old woman with a history of photosensitivity, persistent abdominal pain, and liver dysfunction was admitted to our department because of abdominal pain and progression of liver dysfunction. On admission, levels of protoporphyrin and coproporphyrin within erythrocytes were markedly increased. Autofluorescent erythrocytes were also detected, leading to a diagnosis of erythropoietic protoporphyria. A liver biopsy specimen revealed cirrhosis with dark brown granules filling hepatocytes, bile canaliculi, and bile ductules. Transfusion of washed erythrocytes, hemodialysis, and administration of cholestyramine and beta-carotene transiently improved levels of porphyrins and liver function. The patient died of rupture of esophageal varices followed by multiple organ failure. However, the treatments were believed to have extended survival. Received: September 9, 1998/Accepted: December 18, 1998     

Solid and papillary tumor of the pancreas complicating agenesis of the dorsal pancreas

We report the first documented case of a solid and papillary tumor of the pancreas (SPT) complicating agenesis of the dorsal pancreas. A 28‐year‐old female patient was referred to our hospital for a pancreatic tumor detected at a local hospital. The laboratory findings were all within normal limits. Diagnostic images revealed absence of the dorsal pancreas and the presence of a tumor located in the head of the pancreas. The tumor was solid, well demarcated, noncalcified, and hypovascular. Fine‐needle aspiration cytology revealed that larger cell clumps often had a branching papillary appearance, with multiple layers of tumor cells surrounding central vascular stalks; a preoperative diagnosis of SPT was made. At surgery, on February 10, 1999, the tumor was found to have clear margins, and it showed no signs of direct invasion of adjacent structures. No metastases were found in the liver or the local lymph nodes. Accordingly, partial resection of the pancreas, including the entire tumor, was performed, and, thus, almost the entire head of the pancreas could be saved. Microscopic examination of the resected specimen yielded findings compatible with SPT. No recurrences, and no impairment of pancreatic endocrine or exocrine function have been noted since the operation.     

Successful cochlear implantation in a patient with bilateral progressive sensorineural hearing loss after traumatic subarachnoid hemorrhage and brain contusion

OBJECTIVES: We address the proper indications for cochlear implantation for profound deafness with possible retrocochlear involvement by reporting successful implantation in a patient with traumatic subarachnoid hemorrhage and brain contusion. METHODS: We present a patient (55-year-old man) who had bilateral progressive sensorineural hearing loss after traumatic subarachnoid hemorrhage and brain contusion. Preoperative imaging and functional studies were done, as well as routine tests, to evaluate the possible performance of the cochlear implant. RESULTS: Sensorineural hearing loss developed promptly after head trauma with progressive deterioration. The cause of progressive sensorineural hearing loss remained unknown. Distortion product otoacoustic emissions demonstrated bilateral inner ear (outer hair cell) damage. Highly impaired speech discrimination despite less marked pure tone average elevation and a focal lesion in the left middle temporal gyrus suggested the possibility of coexisting retrocochlear lesions. After thorough discussion of the possible outcomes, cochlear implantation was successfully performed 25 months after the trauma. The patient became able to use a telephone. CONCLUSIONS: We advocate that profound bilateral sensorineural hearing loss caused by traumatic head injury, even with possible involvement of central auditory pathways, should not be regarded as a contraindication to cochlear implantation, as long as bilateral inner ear dysfunction is clearly demonstrated and there is no obvious evidence of central deafness.