A Comparison of Outcomes and Complications of Totally Implantable Access Port Through the Internal Jugular Vein Versus the Subclavian Vein

Totally implantable access ports (TIAPs) are generally used in oncology. Few studies have addressed complications associated with the insertion site. A total of 233 consecutive oncology patients were enrolled to receive TIAP inserts via internal jugular vein (IJV) or subclavian vein (SV). Data on clinicopathologic parameters and early/late complications were retrospectively collected. No differences were found early and late complication rates. Catheter injury was observed more frequently in the IJV group (2.9%) than in the SV group (1.0%) without statistical significance. Multivariate logistic regression analysis showed that age, switch to palliative use of TIAP, and the distribution of diseases (low risk in patients with colorectal cancer) were independent risk factors for determining complications. In conclusion, TIAP insertion site showed no impact on the early and late complication rates. Catheter injury appears to occur at the same frequency with both approaches. Therefore, medical doctors may choose their preferred puncture site when performing TIAP insertion.Key words: TIAP, Internal jugular vein, Central venous port, Totally implantable venous access devices, TIVADTotally implantable access ports (TIAPs) have been widely used for the safe delivery of chemotherapy or parenteral nutrition in patients with malignant disease and other debilitating diseases.¹⁻³ Early complications of TIAP placement have been reported to be pneumothorax, hemothorax, and arterial rupture. Late complications include infection and obstruction or fracture of the catheter.^4,5 The pinch-off syndrome has been thought to reflect the occlusion or fracture of catheters inserted through the subclavian vein (SV).¹ To avoid the occurrence of this syndrome, some researchers recommended that the TIAP catheter should be inserted through the right internal jugular vein (IJV)⁶⁻⁸ or infraclavicular axillary vein under ultrasound guidance.⁹ However, we have reported 2 rare cases of TIAP catheter fracture when introduced through the right IJV.^10,11 Accordingly, we wished to evaluate whether TIAPs inserted via the IJV would present fewer catheter injury and complications than those inserted via the SV. To clarify this issue, we retrospectively compared early and late complications following TIAP insertion in our institute.     

Establishment of Educational Program for Multiorgan Procurement From Deceased Donors

Introduction

Multiorgan procurement is not an easy procedure and requires special technique and training. Since sufficient donors are not available for on-site training in Japan, establishment of the educational program for multiorgan procurement is mandatory.

Materials and methods

Development of e-learning and simulation using pigs are our main goals. E-learning contains three dimensional computer graphic (3DCG) animations of the multiorgan procurement, explanation of both donor criteria and procurement procedure, and self-assessment examination. To clarify the donor criteria, the risk factors to 3-month survival of the recipients were analyzed in 138 adult cases of liver transplantation. The 3DCG animation for liver procurement was developed, which was used in the lecture prior to the simulation on August 10, 2013. The results of the examination after this lecture (exam 2013) were compared with the results after the lecture without using animation in 2012 (exam 2012). The simulation was performed by 97 trainees divided into 9 teams, and the surveys were conducted.

Results

The risk factors for early outcome of the recipients were cold ischemia time (≥10 hours), Model for End-stage Liver Disease score (≥20), and donor age (≥55 years). Results of examination showed that overall percentage of the correct answers was significantly higher in exam 2013 than in exam 2012 (48.3% vs 32.7%; P = .0001). The survey after the simulation of multiorgan procurement revealed that most trainees thought that the simulation was useful and should be continued.

Conclusion

The novel educational program could allow young surgeons to make precise assessments and perform the exact procedure in the multiorgan procurement.     

Chronic Immune-Mediated Reaction Syndrome as the Cause of Late Graft Mortality in Living-Donor Liver Transplantation for Primary Biliary Cirrhosis

Introduction

Few studies to date have investigated the causes of late graft mortality after living-donor liver transplantation (LDLT) for primary biliary cirrhosis (PBC).

Patients and Methods

Fifty-five LDLTs for PBC were retrospectively reviewed. Factors prognostic of graft survival after LDLT were investigated, and histologic findings in patients with late graft loss were assessed.

Results

The 1-, 5-, and 10-year cumulative graft survival rates were 85.1%, 82.5%, and 66.9%, respectively. Multivariate Cox regression analysis found that male donor and ≥4 HLA mismatches were independently associated with poor graft survival. Among the 13 grafts lost, 5 were lost >1 year after LDLT, including 1 each due to chronic rejection, veno-occlusive disease, and obliterative portal venopathy, and 2 to other causes. Pathologic reviews of the serial biopsy specimens and explanted grafts from these 5 patients, with graft rejections from “chronic immune-mediated reaction syndrome,” showed reciprocal changes over time. No patient died of recurrent PBC.

Conclusions

Male donor and ≥4 HLA mismatches were independent factors associated with poor graft survival. Late graft mortality after LDLT for PBC in some patients was due to chronic immune-mediated reaction syndrome, including chronic rejection, veno-occlusive disease, and obliterative portal venopathy, but not to recurrent PBC.     

Two-step Selection Criteria for Living Donor Liver Transplantation in Patients With Hepatocellular Carcinoma

We have proposed risk factors for tumor recurrence, such as tumor nodule ≥5 cm and des-gamma-carboxy prothrombin ≥300 mAU/mL after living donor liver transplantation (LDLT) for hepatocellular carcinoma (HCC). The aim of this study was to clarify the risk factors for HCC recurrence and mortality within our criteria. We enrolled 152 adult recipients who had undergone LDLT for end-stage liver disease with HCC who met our criteria. The recurrence-free survival rates after LDLT were calculated. Risk factors for tumor recurrence were identified. On univariate analysis, factors affecting recurrence-free survival were pretransplant treatment for HCC, neutrophil-to-lumphocyte ratio (NLR) >4, alpha-fetoprotein ≥400 ng/mL, ≥5 nodules, and bilobar tumor distribution. Multivariate analysis identified that NLR >4 and ≥5 nodules were independent risk factors for tumor recurrence after LDLT (P = .003 and P = .002, respectively). Two-step selection criteria enable selection of patients who have high-risk of tumor recurrence.     

Transrectal peritoneal access with the submucosal tunnel technique in NOTES: a porcine survival study

Background

Natural orifice transluminal endoscopic surgery (NOTES) procedures have been performed via transgastric, transvaginal, or transcolonic approaches. However, the transcolonic approach has potential disadvantages including intraperitoneal infection. To avoid such disadvantages, we applied the submucosal tunnel technique to transrectal peritoneal access in this study. Study aims are to clarify the technical feasibility of a submucosal tunnel method for transrectal abdominal access and to assess the healing process of the submucosal tunnel histopathologically.

Methods

The study comprised six female pigs. The following procedures were performed: (1) The mucosa was cut after injection of sodium hyaluronate into the submucosa at the upper rectum. (2) Submucosal tunneling was performed by endoscopic submucosal dissection technique. (3) A small incision was made at the end of the tunnel. (4) After transrectal peritoneoscopy, the mucosal incision site was closed with endoclips.

Results

Transrectal peritoneoscopy was successfully performed in all pigs. Necropsy revealed no findings of peritonitis. Histopathologic examination showed good healing of the submucosal tunnel. The wound healing process of the submucosal tunnel on postoperative day 7 was mainly in the inflammatory phase at the mucosal incision site, the proliferative phase at the submucosal tract, and the proliferative/remodeling phase at the seromuscular incision site.

Conclusions

The submucosal tunnel technique appears to be useful and safe for transrectal peritoneal access because healing at the seromuscular incision site proceeded rapidly.     

A rare point mutation in the Ras oncogene in hepatocellular carcinoma

Purpose

The Ras gene is one of the oncogenes most frequently detected in human cancers, and codes for three proteins (K-, N-, and H-Ras). The aim of this study was to examine the mutations in codons 12, 13 and 61 of the three Ras genes in cases of human hepatocellular carcinoma (HCC).

Methods

Paired samples of HCC and corresponding non-malignant liver tissue were collected from 61 patients who underwent hepatectomy. A dot-blot analysis was used to analyze the products of the polymerase chain reaction (PCR) amplification of codons 12, 13, and 61 of K-, N- and H-Ras for mutations.

Results

Only one mutation (K-Ras codon 13; Gly to Asp) was detected among the 61 patients. Interestingly, this patient had a medical history of surgery for both gastric cancer and right lung cancer. No mutations were found in codons 12 and 61 of K-Ras or codons 12, 13 and 61 of the N-Ras and H-Ras genes in any of the HCCs or corresponding non-malignant tissues.

Conclusions

These findings indicated that the activation of Ras proto-oncogenes by mutations in codons 12, 13, and 61 does not play a major role in hepatocellular carcinogenesis.