Successful utilization of coronary covered stents to treat a common hepatic artery pseudoaneurysm secondary to pancreatic fistula after Whipple’s procedure: Report of a case

A 73-year-old man underwent a pylorus-preserving Whipple’s procedure for distal cholangiocarcinoma. His postoperative course was complicated by the formation of a pancreatic fistula, which was initially managed conservatively. On postoperative day (POD) 86, he lost 100 ml of blood from the site of the pancreatic fistula. Contrast-enhanced computed tomography (CT) showed a pseudoaneurysm, 12 mm in diameter, in the common hepatic artery. The diameter of the pseudoaneurysm increased to 15 mm on POD 89, so we implanted coronary covered stents to prevent massive bleeding from rupture and to retain hepatic arterial flow. Six days after implantation, computed tomography findings confirmed a thrombosed pseudoaneurysm as well as patent hepatic arterial flow. Follow-up CT 18 months after surgery showed patent hepatic arterial flow. There have been no signs of rebleeding or abnormal liver function.     

Torsion of the gallbladder in a 3-year-old infant

A 3-year-old girl was admitted to hospital with complaints of severe upper abdominal pain and vomiting. On admission, a board-like rigidity in the right hypochondrium was noted, along with a high white blood cell count and a high C-reactive protein value. Abdominal ultrasonography (US) revealed a left-sided enlarged gallbladder with a thickened wall, without gallstones. Contrast-enhanced computed tomography (CT) demonstrated an enlarged gallbladder without enhancement effects and a cystic duct located on the right side of the gallbladder. The patient underwent an emergency operation following a diagnosis of torsion of the gallbladder. The gallbladder appeared gangrenous, and 180° clockwise torsion was found at the neck of the gallbladder. The gallbladder was straightened and then removed without difficulty because there was only slight inflammation around Calot’s triangle and the gallbladder was not fixed to the liver. Histopathological examination revealed an acute bleeding infarction of the gallbladder. The patient was discharged on the ninth day after surgery, without any complications. The present case suggested that abdominal US and contrast-enhanced CT examinations are helpful in making a correct diagnosis of torsion of the gallbladder even in an infant; in the event of this diagnosis, prompt cholecystectomy is necessary.     

Evaluation of Double Tract Reconstruction After Total Gastrectomy in Patients with Gastric Cancer: Prospective Randomized Controlled Trial

Background  The double tract (DT) method was compared with the Roux-en-Y (R-Y) method to identify the optimal reconstruction procedure after total gastrectomy for patients with gastric cancer. The DT reconstruction is as simple as the R-Y, and it can be safely performed even after total gastrectomy. However, these have been no studies evaluating the usefulness of DT reconstruction in comparison to R-Y reconstruction. Methods  A group of 44 patients with gastric cancer were intraoperatively randomized for R-Y (n = 23) or DT reconstruction (n = 21) after total gastrectomy (TG). Body weight, food intake, nutritional conditions, and quality of life (QOL) were determined at 3 and 12 months after the operation. This study is registered with ClinicalTrials.gov, no. NCT00746161. Results  Food intake significantly decreased soon after the operation. No differences were observed between the DT and R-Y groups. The body weight decreased throughout the ensuing period (P < 0.05) and thereafter gradually recovered. However, no differences were observed between the two groups. Among the nutritional laboratory parameters, serum prealbumin, retinol-binding protein, total cholesterol, and triglyceride were decreased soon after the operation. The changes of those parameters were not substantially different between the two groups. The postoperative QOL was evaluated, and no differences were observed between those groups. Conclusions  There were no particular advantages in the DT method after TG in comparison to the simple R-Y method in terms of body weight, QOL, and nutritional conditions, suggesting that the DT method might not be recommended after TG for patients with gastric cancer.     

Prognostic Factors After Resection of Pancreatic Cancer

Objectives  The purpose of this study was to identify important prognostic factors related to the status of a pancreatic tumor, its treatment, and the patient’s general condition. Methods  Between April 1992 and December 2006, 140 patients underwent a pancreatic resection for invasive ductal carcinoma. Prognostic factors were defined by univariate and multivariate analyses. Results  The study included 103 tumors in the head of the pancreas and 37 tumors in the body or tail. The median survival time and the actuarial 5-year survival rate for all patients were 14.5 months and 12.3%, respectively. Using the significant prognostic factors identified by univariate analysis, multivariate analysis revealed that a preoperative serum CA19-9 concentration >100 U/ml (HR = 1.84, p = 0.0074), a tumor size >3 cm (HR = 1.74, p = 0.0235), venous involvement (HR = 2.39, p = 0.0006), a transfusion requirement of ≥1000 ml (HR = 2.23, p = 0.0006), and a serum albumin concentration on 1 postoperative month (1POM) < 3 g/dl (HR = 2.40, p = 0.0009) were significant adverse prognostic factors. The presence of hypoalbuminemia on 1POM significantly correlated with a longer surgical procedure (p = 0.0041), extended nerve plexus resection around the superior mesenteric artery (p = 0.0456), and a longer postoperative hospital stay (p = 0.0063). Conclusion  To improve long-term survival, preserving the patient’s general condition by performing a curative resection with a short operation time and minimal blood loss should be the most important principle in the surgical treatment of pancreatic cancer.     

Mutation of ACTA2 gene as an important cause of familial and nonfamilial nonsyndromatic thoracic aortic aneurysm and/or dissection (TAAD)

Approximately 20% of aortic aneurysm and/or dissection (AAD) cases result from inherited disorders, including several systemic and syndromatic connective‐tissue disorders, such as Marfan syndrome, Ehlers‐Danlos syndrome, and Loeys‐Dietz syndrome, which are caused by mutations in the FBN1, COL3A1, and TGFBR1 and TGFBR2 genes, respectively. Nonsyndromatic AAD also has a familial background, and mutations of the ACTA2 gene were recently shown to cause familial AAD. In the present study, we conducted sequence analyses of the ACTA2 gene in 14 unrelated Japanese patients with familial thoracic AAD (TAAD), and in 26 with sporadic and young‐onset TAAD. Our results identified three mutations of ACTA2, two novel [p.G152_T205del (c.616+1G>T), p.R212Q] and one reported (p.R149C), in the 14 patients with familial TAAD, and a novel mutation (p.Y145C) of ACTA2 in the 26 sporadic and young‐onset TAAD patients, each of which are considered to be causative for TAAD. Some of the clinical features of these patients were the same as previously reported, whereas others were different. These findings confirm that ACTA2 mutations are important in familial TAAD, while the first sporadic and young‐onset TAAD case with an ACTA2 mutation was also identified. Hum Mutat 30:1–6, 2009. © 2009 Wiley‐Liss, Inc.     

Successful effect of triple blockade of renin–angiotensin–aldosterone system on massive proteinuria in a patient with chronic kidney disease

A patient with chronic kidney disease (CKD) due to membranous nephropathy with daily urinary protein excretion exceeding 5 g did not respond well to dual therapy with an angiotensin converting enzyme inhibitor (ACE-I) and angiotensin II receptor blocker (ARB). Addition of the mineralocorticoid receptor blocker (MRB), spironolactone, led to moderate reduction in daily urinary protein excretion. However, spironolactone had to be inevitably discontinued due to gynecomastia. Replacement of spironolactone with the selective MRB, eplerenone, added to the preceding treatment with ACE-I and ARB, resulted in remarkable reduction of daily urinary protein excretion to less than 0.2 g. This case suggests that triple blockade of renin–angiotensin–aldosterone (RAA) system with ACE-I, ARB, and MRB could be useful for CKD patients with massive proteinuria.     

Efficacy of repeat hepatic resection for recurrent hepatocellular carcinomas

Background: This study evaluated the efficacy of repeat hepatic resection for recurrent hepatocellular carcinoma (HCC) and the clinicopathological factors influencing overall survival after resection. Methods: From 1992 to 2005, 231 patients underwent curative hepatic resection for HCC at Yokohama City University, Japan. Of these, 105 patients developed intrahepatic recurrence, and 24 repeat hepatectomies were performed for recurrent HCC. Survival data were analysed, and prognostic factors for repeat hepatic resection were determined. Results: The overall cumulative 1‐, 3‐ and 5‐year survival rates and the median survival time of the patients after initial hepatic resection (n= 231) did not differ from those of the patients after repeat hepatic resection (n= 24), with values of 91.3, 70.2 and 49.1%, and 57 months, versus 91.7, 73.1 and 50.9%, and 61.5 months, respectively (P= 0.875). The operative time and blood loss in patients who underwent repeat hepatic resection did not differ from those who underwent primary resection. Multivariate analysis identified portal invasion at the first hepatic resection and a disease‐free interval of ≤1.5 years after primary hepatic resection as independent risk factors for survival after repeat hepatic resection. The 12 patients who did not show either of the two prognostic factors had 3‐ and 5‐year survival rates of 91.7 and 68.8%, respectively, after repeat hepatic resection. Conclusions: Our findings suggest repeat hepatic resection as the treatment of choice for recurrent HCC patients without portal invasion at the first resection whose recurrence develops after a disease‐free interval of >1.5 years since the previous surgery.