Chronic Pulmonary Disease Caused by Tsukamurella toyonakaense

Unidentified Mycobacterium species are sometimes detected in respiratory specimens. We identified a novel Tsukamurella species (Tsukamurella sp. TY48, RIMD 2001001, CIP 111916^T), Tsukamurella toyonakaense, from a patient given a misdiagnosis of nontuberculous mycobacterial pulmonary disease caused by unidentified mycobacteria. Genomic identification of this Tsukamurella species helped clarify its clinical characteristics and epidemiology.     

Structural elements influencing von Willebrand factor (vWF) binding affinity for platelet glycoprotein Ib within a dispase-digested vWF fragment

We investigated the structural elements in human von Willebrand factor (vWF) that influence binding affinity for platelet glycoprotein (GP) Ib using a dispase-digested vWF fragment as a prototype (residues Leu480/Val481-Gly718 of the vWF subunit; Andrews et al, Biochemistry 28:8326, 1989). The major structural features of this fragment are a large A1-loop formed by an intrachain disulfide bond between Cys509 and Cys695 and six O-linked sugar chains. The fragment was chemically modified by (1) reduction and S-carboxyamido-methylation (R/A), (2) desialylation (DS), or (3) a combination of both (R/A-DS). The GPIb binding affinity of these fragments was basically evaluated by competitive binding assay with anti-GPIb monoclonal antibody (LJ-Ib1), a receptor blocker for vWF (Sugimoto et al, Biochemistry 30:5202, 1991). Both the prototype and the R/A fragments were also assessed for their function in shear-induced platelet aggregation. Results unambiguously demonstrated that the presence of a disulfide bridge (Cys509-Cys695) within this domain downregulates the affinity of vWF to GPIb. In addition, it was also demonstrated that the terminal sialic acids attached to six o-linked sugar chains within this domain contribute to optimal functional modulation by the antibiotic ristocetin, but not by snake venom botrocetin.     

Management under anesthesia of a patient with renal cell carcinoma extending into the retrohepatic inferior vena cava with the aid of partial cardiopulmonary bypass]

A 70-year-old male with renal cell carcinoma extending into the retrohepatic inferior vena cava was scheduled for radical nephrectomy with vena caval resection under general anesthesia. He had received partial gastrectomy for gastric cancer twelve years before. Computed tomography and inferior vena cavography confirmed that the vena cava was almost completely occluded and that a collateral venous network was well established. It was considered that the surgical approach to the retrohepatic cavals area was technically very difficult, and that there was a high possibility of a pulmonary embolus during the surgical manipulation. To prevent a pulmonary embolus and get good control of the vena cava above the tumor and below the hepatic vein, we decided to use a partial cardiopulmonary bypass (CPB) until the vena cava was clamping above the tumor. Anesthesia was induced with propofol and fentanyl, and maintained with fentanyl and isoflurane-N2O-O2. In the partial CPB blood from the hepatic vein was drained from the inferior vena cava cannula through right atrium, oxygenated by microporus membrane oxygenator, and returned to the left femoral artery. Cannulation to drain the venous circulation entering the vena cava below the tumor was abandoned because the extensive collateral venous network ultimately drains into the superior vena cava. The partial CPB time was 90 min, and the bladder temperature during the CPB was 35-36 degrees C. During the 7.3 hr procedure, the pulmonary embolus did not occur and the total blood loss was 5515 ml. The patient made an uncomplicated recovery and was discharged 30 days after the operation. This newly reported partial-CPB method may be safe and effective for the management under anesthesia of other patients.     

Salvage Hepatectomy for Local Recurrent Hepatocellular Carcinoma After Ablation Therapy

Background

The results of salvage hepatectomy for local recurrent hepatocellular carcinoma after incomplete percutaneous ablation therapy are still unclear.

Methods

We conducted a retrospective analysis of 197 consecutive patients with hepatocellular carcinoma who underwent either salvage hepatectomy after prior incomplete percutaneous ablation therapy (salvage group; n?=?23) or primary hepatectomy as the initial treatment (primary group; n?=?174). The two groups were compared with respect to intraoperative data, operative mortality and morbidity, and long-term survival.

Results

The salvage group showed a significantly longer operation time (385 vs. 300?min; P?=?0.006) and a significantly greater intraoperative blood loss volume (402 vs. 265?ml; P?=?0.024). The postoperative mortality rate was zero in both groups, and the morbidity rates were similar. Although the 1-, 3-, and 5-year disease-free survival rates after hepatectomy were significantly worse in the salvage group than in the primary group (65%, 41%, and 33% vs. 81%, 51%, and 45%, respectively; P?=?0.031), the overall survival rates after hepatectomy did not differ significantly (91%, 91%, and 67% vs. 96%, 79%, and 65%, respectively; P?=?0.790). The 1-, 3-, and 5-year overall survival and disease-free survival rates after percutaneous ablation therapy were also not different from those in the primary group (100, 96, and 83%, P?=?0.115; and 96, 60, and 45%, P?=?0.524, respectively).

Conclusions

The short-term and long-term results of salvage hepatectomy after incomplete percutaneous ablation therapy are equivalent to those of primary hepatectomy. Salvage hepatectomy is an acceptable treatment for patients with local recurrence of hepatocellular carcinoma after ablation therapy.     

Risk factors affecting late-presenting liver failure in adult patients with biliary atresia

Purpose

Following the Kasai operation, a number of patients have developed liver failure, even after long-term postoperative courses. We assessed the clinical parameters to clarify the early risk factors affecting late-presenting liver failure in biliary atresia.

Materials and Methods

From 1955 to 1991, 277 patients underwent a Kasai operation. Among those patients, 92 survived with their native liver for more than 20 years, and 72 continue to survive with their native liver in good condition (Group 1). In 20 patients, persistent jaundice recurred after the age of 20 years (Group 2). The postoperative courses of these patients were assessed retrospectively, and the clinical parameters, including age at the time of the Kasai operation (AGE, days), the period required for jaundice to disappear (PJD, days), and the association with early cholangitis (CG), were compared between the 2 groups.

Results

Of the 20 patients in Group 2, 8 survived after a liver transplantation (LTx). Eight patients had recurrent jaundice, including 4 on the waiting list for anLTx. Additionally, 2 patients died after anLTx at the ages of 22 and 39. Another patient died of liver failure at the age of 28. One patient died of massive esophageal variceal bleeding at the age of 29. Significant differences were confirmed with respect to AGE (Group 1 < Group 2, p < .001), PJD (Group 1 < Group 2, p < .001), and CG (Group 1: Group 2 = 47 %: 75 %, p = .028).

Conclusions

A considerable number of adult patients developed liver failure, even after the age of 20 years. AGE, PJD, and CG were found to be risk factors affecting late-presenting liver failure. Therefore, close patient follow-up is essential, especially for long-term survivors with a late operative age and early postoperative complications.     

Surgical Treatment for Biliary Carcinoma Arising After Pancreatoduodenectomy

The clinicopathological features and surgical treatment of biliary carcinoma around the major hepatic duct confluence arising after pancreatoduodenectomy (PD) due to initial bile duct carcinoma are described in three patients. Occurrence of biliary carcinoma more than 12 years after initial surgery and a histological finding of cholangiocellular carcinoma mixed with hepatocellular carcinoma suggested metachronous incidence of biliary carcinoma after PD. Extended right hemihepatectomy with complete removal of the residual extrahepatic bile duct and segmental, resection of the jejunal loop were carried out safely without operative death or severe postoperative complications. Two patients died of tumor recurrence 6 months after surgery, and the remaining patient is currently living a normal life without evidence of recurrence 17 months after surgery. These surgical procedures are a therapeutic option in patients with biliary carcinoma around the major hepatic duct confluence arising after PD.     

Intraluminal lavage to remove exfoliated tumor cells after colorectal endoscopic submucosal dissection

Background

Endoscopic submucosal dissection (ESD) involves dissection of tumors and manipulation of them in an exposed condition for prolonged periods. A large number of tumor cells are exfoliated into the intestinal lumen after colorectal ESD. The aim of this study was to determine whether lavage volume has an influence on tumor cell clearance after colorectal ESD.

Methods

Twenty patients who underwent colorectal ESD at our hospital between July 2013 and December 2014 were studied. Cytological examination of intraluminal lavage samples associated incremental increases in lavage volume was collected. This prospective study was approved by the ethics committee of our hospital.

Results

No patients had exfoliated tumor cells in their samples before ESD. Four patients (20 %) had exfoliated tumor cells in their samples after lavage with 500 ml, while one patient (5 %) had exfoliated tumor cells after lavage with 1000 or 1500 ml.

Conclusion

Tumor cells are exfoliated into the intestinal lumen by tumor manipulation during colorectal ESD. There seems to be a risk for implantation after ESD, as well as rectal surgery. Sufficient intraluminal lavage of more than 1000 ml may be desirable to remove exfoliated tumor cells after colorectal ESD.

     

Morphologic Features of Carotid Plaque Rupture Assessed by Optical Coherence Tomography

BACKGROUND AND PURPOSE:Rupture of the plaque fibrous cap and subsequent thrombosis are the major causes of stroke. This study evaluated morphologic features of plaque rupture in the carotid artery by using optical coherence tomography in vivo.MATERIALS AND METHODS:Thirty-six carotid plaques with high-grade stenosis were prospectively imaged by optical coherence tomography. “Plaque rupture” was defined as a plaque containing a cavity that had overlying residual fibrous caps. The fibrous cap thickness was measured at its thinnest part for both ruptured and nonruptured plaques. The distance between the minimum fibrous cap thickness site and the bifurcation point was also measured. Optical coherence tomography identified 24 ruptured and 12 nonruptured plaques.RESULTS:Multiple ruptures were observed in 9 (38%) patients: Six patients had 2 ruptures in the same plaque, 2 patients had 3 ruptures in the same plaque, and 1 patient had 5 ruptures in the same plaque. Most (84%) of the fibrous cap disruptions were identified at the plaque shoulder and near the bifurcation point (within a 4.2-mm distance). The median thinnest cap thickness was 80 μm (interquartile range, 70–100 μm), and 95% of ruptured plaques had fibrous caps of <130 μm. Receiver operating characteristic analysis revealed that a fibrous cap thickness of <130 μm was the critical threshold value for plaque rupture in the carotid artery.CONCLUSIONS:Plaque rupture was common in high-grade stenosis and was located at the shoulder of the carotid plaque close to the bifurcation. A cap thickness of <130 μm was the threshold for plaque rupture in the carotid artery.

Rupture of the fibrous cap and subsequent thrombosis are the major causes of cardiovascular events such as heart attack and stroke.^1–3 In a previous study of sudden coronary death, a fibrous cap thickness of 65 μm was chosen as a criterion of instability because for a cap to rupture, the average cap thickness was 23 ± 19 μm; 95% of caps measured <65 μm within a limit of only 2 SDs.¹ Therefore, the fibrous cap thickness of <65 μm is now widely accepted as the definition of in vivo coronary vulnerable plaque that is prone to rupture. Disruption of the fibrous cap is frequently observed in symptomatic carotid plaques^4,5 and is strongly associated with an ulceration appearance on angiography,⁶ which is considered an independent predictor of stroke on long-term follow-up in patients with symptomatic severe carotid stenosis.⁷ Redgrave et al⁸ examined the cross-sections of plaques with high-grade carotid stenosis and found that the optimum fibrous cap thickness for discriminating ruptured and nonruptured plaques was 200 μm; thus, it appears that there is no clear threshold for classifying plaques that are prone to rupture in vivo.Intravascular sonography, which is a widely used imaging method in the field of carotid artery intervention, has an axial resolution of 100–200 μm and a lateral resolution of 250 μm.⁹ Although it can visualize deep structures, intravascular sonography is not a suitable imaging technique for the detection of thin fibrous caps because its resolution is too low. Optical coherence tomography (OCT) has been introduced recently as a high-resolution imaging method.^10,11 The typical OCT image has an axial resolution of 10 μm, approximately 10 times higher than that of any other clinically available diagnostic imaging technique, such as intravascular sonography. OCT provides an accurate representation of the thickness of the fibrous cap that could not be measured by other imaging modalities.¹² In the present study, we evaluated the morphologic features of ruptured plaques in the carotid artery by using OCT.     

A case of recurrent cholangitis after bile duct injury during laparoscopic cholecystectomy: Value of scintigraphy with Tc-99m GSA and hepatobiliary scintigraphy for indication of lobectomy

A 39-year-old woman with acute cholecystitis and gallstones underwent laparoscopic cholecystectomy. She suffered from recurrent episodes of cholangitis due to injury of the major bile ducts during laparoscopic cholecystectomy. Hepatobiliary scintigraphy with Tc-99m Sn-N-pyridoxyl-5-methyltryptophan was performed. Although normal bile excretion was found from the left hepatic duct to the percutaneous transhepatic biliary drainage (PTBD) tube, excretion from the right hepatic lobe was prolonged. Scintigraphy with Tc-99m diethylenetriaminepentaacetic acid-galactosyl human serum albumin demonstrated atrophy of the right hepatic lobe and enlargement of the left hepatic lobe. Cholangiography via the PTBD tube revealed complete obstruction of the left hepatico-jejunal anastomosis and could not enhance the right intrahepatic bile duct. A right hepatic lobectomy was performed because of the atrophy, glissonitis and the absence of an appropriate bile duct for reconstruction. Postoperatively she was active and exhibited no evidence of recurrent cholangitis.