Unforeseen encounter of acquired hemophilia A in a preoperative case of periampullary carcinoma: A case report

IntroductionAcquired hemophilia A (AHA) is a rare disorder characterized by development of antibodies against factor VIII, which can present as paraneoplastic syndrome in various malignancies like periampullary cancer, cancer of lung, prostate, gastrointestinal stromal tumour and non malignant cases like pregnancy, autoimmune disease and medication.Case presentationWe report a case of elderly man presented with paraneoplastic AHA in periampullary carcinoma in preoperative period which was diagnose by mixing study and inhibitor assay and managed with bypass agents like recombinant factor VII, FEIBA and immunosuppresion to eliminate inhibitor with help of steroid, cyclophosphamide and emicizumab. Patient underwent Whipple’s pancreaticoduodenectomy after which coagulation study became normal in immediate postoperative period. Patient was discharged and followed up with chemotherapy.Clinical discussionPeriampullary carcinoma presenting as AHA is rare and rarer in pre-operative settings. The usual mode of presentation is bleeding after biopsy and from minor surgical scars. The pathogenesis is yet to be delineated. It is managed by factor VIII administration and immunosuppressive therapy.ConclusionHigh index suspicion should be there to diagnose AHA as a paraneoplastic manifestation and elective surgery should be delayed till normalization of coagulation parameters.     

Cutaneous Malignancies After Kidney and Simultaneous Pancreas-Kidney Transplantations

BackgroundOrgan transplant recipients are at increased risk of nonmelanotic skin cancers (NMSC). Scarce data exist regarding secondary malignancies developing post–simultaneous pancreas-kidney (SPK) transplantations. Our aim was to assess long-term risk of skin cancers among kidney alone (KA) and SPK transplantation recipients.MethodsIn this study, 521 patients who underwent KA or SPK transplantation at our medical center were observed up by dedicated nephrologists and dermatologists. SPK transplantation recipients were matched with a control group of KA transplantation recipients based on demographic and clinical data. A multivariate analysis was performed to find independent cancer risk factors.ResultsPatients who developed skin cancer were generally older, had a fair skin type, and had a higher incidence of NMSC before transplantation. Older age and fair skin type were independent risk factors on multivariate analysis. SPK transplantation in itself was not an independent risk factor. Cancer recurrence was associated with older age and male sex. Darker skin type and lowered immunosuppressive burden were protective.ConclusionIn contrast to previous studies, the use of antithymocytic agents or SPK transplantation were not independently associated with increased skin cancer risk in this multivariate analysis. These findings emphasize the complex interplay between posttransplantation NMSC and various clinical and epidemiologic risk parameters.     

Enhancing capsule in hepatocellular carcinoma: intra-individual comparison between CT and MRI with extracellular contrast agent

PurposeThe purpose of this study was to compare the value of contrast-enhanced computed tomography (CT) to that of magnetic resonance imaging obtained with extracellular contrast agent (ECA-MRI) for the diagnosis of a tumor capsule in hepatocellular carcinoma (HCC) using histopathologic findings as the standard of reference.Materials and methodsThis retrospective study included patients with pathologically-proven resected HCCs with available preoperative contrast-enhanced CT and ECA-MRI examinations. Two blinded radiologists independently reviewed contrast-enhanced CT and ECA-MRI examinations to assess the presence of an enhancing capsule. The histopathological analysis of resected specimens was used as reference for the diagnosis of a tumor capsule. The sensitivity and specificity of CT and ECA-MRI for the diagnosis of a tumor capsule were determined, and an intra-individual comparison of imaging modalities was performed using McNemar test. Inter-reader agreement was assessed using Kappa test.ResultsThe study population included 199 patients (157 men, 42 women; mean age: 61.3 ± 13.0 [SD] years) with 210 HCCs (mean size 56.7 ± 43.7 [SD] mm). A tumor capsule was present in 157/210 (74.8%) HCCs at histopathologic analysis. Capsule enhancement was more frequently visualized on ECA-MRI (R1, 68.6%; R2, 71.9%) than on CT (R1, 44.3%, P < 0.001; R2, 47.6%, P < 0.001). The sensitivity of ECA-MRI was better for the diagnosis of histopathological tumor capsule (R1, 76.4%; R2, 79.6%; P < 0.001), while CT had a greater specificity (R1, 84.9%; R2, 83.0%; P < 0.001). Inter-reader agreement was moderate both on CT (kappa = 0.55; 95% confidence interval [CI]: 0.43–0.66) and ECA-MRI (kappa = 0.57; 95% CI: 0.45–0.70).ConclusionCapsule enhancement was more frequently visualized on ECA-MRI than on CT. The sensitivity of ECA-MRI was greater than that of CT, but the specificity of CT was better than that of ECA-MRI.     

肝细胞移植的研究现状与进展

肝细胞移植是一种通过对获得的正常肝组织进行体外分离纯化,并将分离纯化的肝细胞植入患者体内暂时性地对遗传性代谢性肝病和急性肝衰竭等患者提供代谢性支持的新方法。经过多年的发展,肝细胞移植技术已经取得很大的进展,目前在临床应用已有成功案例,但距离临床广泛应用仍需要进一步的研究。     

Impact of Postoperative Complications on Long-Term Survival After Resection of Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

Annals of Surgical Oncology - Controversy exists over the relationship between postoperative complications (POCs) and long-term survival for hepatocellular carcinoma (HCC) after hepatectomy. This...     

Hématome infecté du cul-de-sac de Douglas : une complication spécifique de la chirurgie de l’endométriose profonde postérieure du fond vaginal

ObjectiveSurgical management of deep pelvic endometriosis may be responsible for various complications, such as infected pelvic haematic collection of the Douglas pouch. The aim of this study is to describe this unfavourable outcome and to estimate its frequency in the series of women managed by our team.Patients and methodsRetrospective study enrolling 163 women undergoing surgical removal of deep posterior endometriosis involving the vagina, from January 2008 to September 2011. We indentified women presenting with postoperative fever associated with computed tomographic findings suggesting an abscess of the Douglas pouch. Women characteristics, complication's management and outcomes were analysed in each case.ResultsTen patients presented an inflammatory syndrome associated to hypothetical Douglas pouch abscess, revealed 6 days postoperatively on average. All women reported increasing pelvic pain, fever higher than 38.5 °C, increased level of leucocytes and C reactive protein, and liquid collection of the Douglas pouch. Surgical management was carried out in nine women, revealing a pelvic collection of cloudy haematic liquid. Various bacteria were identified in six cases out of nine, suggesting liquid contamination through vagina opening. Postoperative outcome were immediately favourable.Discussion and conclusionInflammatory syndrome associated with infected haematic collection of the Douglas pouch is a postoperative complication of the surgical removal of deep endometriosis involving the posterior vagina. Surgical removal of the haematic collection allows rapid and definitive favourable outcomes.     

Effects of Administration Route of Adipose-Derived Stem Cells on the Survival of Allogeneic Skin Grafts in Mice

BackgroundComposite tissue allotransplantation presents considerable potential for defective tissue reconstruction. However, the high immunogenicity of the allogeneic skin grafts can cause acute rejection. Adipose-derived stem cells (ADSCs) reportedly have an immunomodulation potential, which may improve the survival of allogeneic skin grafts. However, there is currently no consensus on administration route of ADSCs. This study compared the effectiveness of local injection vs intravenous (IV) administration of ADSCs in improving the survival of allogenic skin grafts in mice.MethodsBALB/c and C57BL/6 mice were used as skin graft donors and recipients, respectively. Mice were divided into 3 groups for IV injection of ADSCs (IV group) or phosphate-buffered saline (PBS; control), or for local injection in the fascial layer of the recipient bed (FL group). After allogeneic skin transplantation, 0.1 mL of PBS alone or with 1.5 × 10⁵ ADSCs was immediately injected. The grafts were histologically evaluated on days 7 and 14 postoperation.ResultsThe graft necrotic area was significantly smaller in the IV and FL groups than in the control group. Additionally, the grafts in these 2 groups exhibited decreased interleukin 17/6, tumor necrosis factor-α, and interferon-γ messenger mRNA levels; inflammatory changes; and cluster of differentiation 4 expression, and increased expression of vascular endothelial growth factor expression (P < .05). However, these 2 groups did not significantly differ (P > .05).ConclusionsADSCs increased the survival of allogeneic skin grafts in mice regardless of IV or FL route of administration, and this effect is likely through anti-inflammatory and angiogenic effects of ADSCs.     

Prognostication of critically ill patients with acute-on-chronic liver failure using the Chronic Liver Failure–Sequential Organ Failure Assessment: A Canadian retrospective study

PurposeWe evaluated the Chronic Liver Failure–Sequential Organ Failure Assessment (CLIF-SOFA) score to predict survival in a Canadian critically ill cohort with acute-on-chronic liver failure.MethodsWe retrospectively examined 274 acute-on-chronic liver failure patients admitted to a quaternary level intensive care unit (ICU) between April 1, 2000, and April 30, 2011. We evaluated severity of illness scores, including the Acute Physiology and Chronic Health Evaluation (APACHE) II, model for end-stage liver disease (MELD), Child-Turcotte-Pugh (CTP), SOFA, and CLIF-SOFA.ResultsOn ICU admission, patients had the following median (interquartile range): APACHE II, 23 (19-28); MELD, 26 (19-35); CTP, 12 (10-13); SOFA, 15 (11-18); and CLIF-SOFA, 17 (13-21). In-hospital survival was 40%. There were no significant differences in survival for cirrhosis etiology, reason, or year of admission. The CLIF-SOFA score had the greatest area under receiver operating curve of 0.865 (95% confidence interval, 0.820-0.909) and outperformed the CTP, MELD, SOFA, and APACHE II scores. Sequential Organ Failure Assessment score performance improved on the third day of ICU admission (area under receiver operating curve, 0.935; 95% confidence interval, 0.895-0.975).ConclusionsThe CLIF-SOFA and SOFA scores during the first 3 days of ICU admission appear to be highly predictive of in-hospital mortality.