Thrombopoietin in postoperative thrombocytopenia following living donor hepatectomy.

Thrombocytopenia is a frequent finding following living donor hepatectomy. It appears more pronounced in right graft donors than in left graft donors. This study analyzed postoperative thrombocytopenia in 20 living liver donors and examined the change of endogenous thrombopoietin (TPO) in its recovery. Platelet count, TPO level, fibrinogen degradation product (FDP), and D-Dimer were measured before surgery and on postoperative days (PODs) 1, 2, 3, 5, 7, and 14. Concurrently, liver and spleen volumes were calculated by computed tomography. Platelet count on POD 3 was significantly lower in right graft donors than in left graft donors (13.0 +/- 3.7 x 10(4)/microL vs. 16.8 +/- 4.0 x 10(4)/microL, P = 0.039) but recovered by POD 7 in all donors. Postoperative elevations of FDP and D-Dimer were significantly higher in right graft donors than in left graft donors. TPO level rose immediately after surgery, peaked on POD 5 in left graft donors and on POD 7 in right graft donors, and fell nearly to preoperative levels by POD 14. Postoperative TPO level per liver volume was significantly higher in right graft donors than in left graft donors. In conclusion, thrombocytopenia following living donor hepatectomy resolved within the first week regardless of graft type and was mainly associated with increasing consumption of circulating platelets, possibly due to intrahepatic and splenic congestion. With a reduced number of circulating platelets, TPO level rapidly increases. Also, with reduced consumption of platelets related to recovery from surgery, thrombocytopenia should resolve. As a consequence, TPO level would be expected to fall.     

Spontaneous Rupture of the Spleen Secondary to Metastatic Hepatocellular Carcinoma: A Report of a Case and Review of the Literature

An extremely rare case of splenic rupture at the site of metastasis of hepatocellular carcinoma is reported. A 62-yr-old woman with hepatocellular carcinoma and its suspected metastasis to the spleen died of intraperitoneal hemorrhage. Autopsy disclosed a laceration of the spleen as the definitive cause of the hemorrhage. There were multiple nodules of metastatic hepatocellular carcinoma in the spleen, some of which were exposed at the lacerated portion of the splenic capsule. This may be the first report of a case of spontaneous rupture of the spleen secondary to metastatic hepatocellular carcinoma. Splenic rupture can he one of the causes of hemoperitoneum in patients with hepatocellular carcinoma.     

Clinicopathologic evaluation of the trend toward histologically poor differentiation with submucosal invasion in superficial early colorectal adenocarcinomas

We examined differences in the degree of differentiation in intramucosal and submucosal areas of involvement in early colorectal adenocarcinomas of 131 patients and compared these findings with tumor morphology. In addition, K-ras and p53 protein expression was determined in cases where poorly differentiated adenocarcinoma was detected in the submucosa. We identified 6 patients with both intramucosal differentiated (well-to-moderately differentiated) adenocarcinoma and submucosal poorly differentiated adenocarcinoma (MwSp). The morphological tumor type was superficial in all MwSp cases. The observed MwSp adenocarcinomas had a significantly higher frequency of lymphatic invasion than the more common superficial type of adenocarcinoma. Genetic analysis of these MwSp lesions was carried out using the polymerase chain reaction-restriction fragment-length polymorphism (PCR-RFLP) method to detect the presence of K-ras codon 12 point mutations, and an immunologic staining technique was used to identify the presence of p53 protein overexpression. The K-ras mutation rate was 33.3%, and the p53 overexpression rate was 66.7% for the MwSp adenocarcinomas. Our findings suggest that the rapidly reduced histologic differentiation observed in some of these superficial colorectal adenocarcinomas may play a role in their higher degree of invasiveness. Received: November 17, 1999 / Accepted: July 7, 2000     

Hard palate mucoperiosteal graft for posterior lamellar reconstruction of the upper eyelid: histologic rationale

Reconstruction of full-thickness upper eyelid defects often requires repair of both the anterior lamella (skin and orbicularis oculis muscle) and the posterior lamella (tarsus and conjunctiva). Various autogenous grafts have been used for posterior lamellar reconstruction, but it is still unclear which material is most suitable for repairing the posterior lamella. We report a patient in whom a subtotal defect of upper eyelid was reconstructed with a bipedicled myocutaneous flap lined by hard palate mucoperiosteum. We also examined tarsoconjunctiva, labial mucosa, hard palate mucoperiosteum, and auricular cartilage histologically and assessed the histologic features of these tissues as substitutes for the posterior lamella. An even and stable upper eyelid was formed by our method of reconstruction. A mucoperiosteal graft from the hard palate bears a close resemblance to the tarsoconjunctiva histologically because it contains both fibrous connective tissue and a mucous membrane. The graft took completely and there was no donor site morbidity or postoperative complications. A hard palate mucoperiosteal graft may be an optimal substitute for the posterior lamella of the upper eyelid.     

Endoscopic appearance of the colon and small intestine of a patient with hemorrhagic enteric graft-vs.-host disease

Endoscopic appearance of the gastrointestinal tract of a patient with severe hemorrhagic enteric graft-vs.-host disease (GVHD) is presented. A 29-year-old man with chronic myelogenous leukemia suffered from severe enteric GVHD after allogeneic bone marrow transplantation. Endoscopy showed hemorrhagic ulceration of the upper jejunum, terminal ileum, and colon at the onset of melena. Sections of biopsies were compatible with acute GVHD. Repeat endoscopy showed gradual healing of the lesions after steroid pulse and antilymphocyte globulin therapy, but the patient died of cytomegalovirus pneumonitis 14 months later. Autopsy revealed submucosal fibrosis of the small intestine and colon.     

Fetal ultrasonography to prevent irreversible neurological sequelae of neonatal neuroblastoma

An intra-abdominal mass was observed by fetal ultrasonography at 32 weeks of gestation. The baby was diagnosed as having neuroblastoma at the time of delivery at 39 weeks and its lower extremities were completely paralyzed. The chemotherapy after birth was quite effective to reduce the mass volume but neurological sequelae failed to improve. By carefully monitoring the movement of extremities, it may have been possible to prevent irreversible paralysis by inducing delivery before that state was reached.     

Liver regeneration in living-donor liver transplantation

Liver regeneration in living-donor liver transplantation is summarized from the authors' data. In donors, liver function tests recovered to within the normal range 2 weeks after surgery regardless of graft type. At 2 weeks, the volumetric recovery of the remnant liver was 65% and 80% of the original volume in right and left lobe donors, respectively. These results suggest that functional recovery occurs earlier than morphologic restoration in donors. In recipients, the factor that affected the regeneration rate in size 4 weeks after transplantation was only implanted graft size; the rate was greater in patients in whom smaller grafts were implanted. In recipients with a rate of two or more, however, high portal vein pressure and flow were observed. Further, persistent low platelet counts and hyperbilirubinemia were seen in those patients. These results indicate that size enlargement may be caused by engorgement, and functional recovery is not achieved concurrently with morphologic restoration, especially in patients with smaller grafts. In patients with fulminant hepatic failure who receive auxiliary partial orthotopic liver transplantation, sequential histopathologic observations of the diseased liver revealed that liver regeneration initiates from cytokeratin 17-positive ductules and at least 1 year is necessary for complete recovery.     

Arterial hypertension following renal transplantation in children—a short-term study

Systemic arterial hypertension is a common complication among transplanted patients. The objective of this study was to investigate the risk factors for arterial hypertension after kidney transplantation in children. A retrospective study was carried out of 70 kidney transplants performed on patients under 18 years of age at the Hospital do Rim and Hipertensão, from January 1998 to June 2001. At the end of 6 months post transplant, the patients were classified into either normotensive (n=31) or hypertensive (n=39) groups. The following potential risk factors for arterial hypertension were studied: (1) hypertension before transplantation; (2) the glomerular filtration rate (GFR) at 1, 3, and 6 months post transplant; (3) acute rejection episodes; (4) cumulative dose of corticosteroids; (5) the presence of native kidneys; (6) symptomatic renal artery stenosis; (7) cold ischemia time greater than 24 h; (8) age and sex of the donor; (9) age of the recipient; (10) transplant type (living related or cadaveric donor); (11) the body mass index of recipients at the end of the follow-up period; and (12) delayed graft function. The two groups were comparable in terms of the etiology of renal insufficiency, age, gender, and immunosuppressive drugs. Among the risk factors studied, the sole factor showing a statistically significant association with arterial hypertension was the GFR at 3 and 6 months after transplantation. In the group of normotensive patients, GFRs were 92±29 and 83±20 ml/min per 1.73 m² at 3 and 6 months, respectively, whereas in the hypertensive patients, GFRs were 74±23 and 70±21 ml/min per 1.73 m² respectively. Hence, only the lower GFR can be considered a risk factor for hypertension in children within our sample. However, arterial hypertension might be a risk factor for the early onset of chronic allograft nephropathy; in this case, hypertension should be considered the cause of lower glomerular filtration. Our data do not permit us to distinguish between these two hypotheses. The known risk factors for hypertension following renal transplantation in adults were not confirmed in the present study. It remains unclear to us as to whether this means the etiology of hypertension differs in children, or if this is the result of a bias in patient selection.     

Evaluation of malignancy using Ki-67 labeling index for gastric stromal tumor

Background. Assessment of malignant potential in gastrointestinal stromal tumors (GISTs) is still problematic. The maximum tumor diameter and the mitotic index are generally used as an index of malignancy of GISTs. The Ki-67 labeling index has recently been used as an index of cell growth, and the prognosis of GISTs was reported to be significantly poor when the value of this index was 10% or higher. Methods. Clinicopathological and immunohistological factors were analyzed in 15 patients who underwent surgical resection of gastric stromal tumors at our department between April 1997 and July 2002. The patients were divided into metastasis/recurrence and benign groups. Also, the relationship of changes in the Ki-67 labeling index to the degree of malignancy in recurrent lesions was assessed in an 84-year-old woman who underwent five reoperations because of recurrences in the peritoneum. Results. Significant differences were noted between the metastasis/recurrence and benign groups in relation to the mean maximum tumor diameter (186.7 ± 80.8mm vs 41.3 ± 22.9mm), mitotic index (88.3 ± 5.0/50 high-power fields [HPF] vs 3.0 ± 2.9/50 HPF), and the Ki-67 labeling index (11.4 ± 2.5% vs 0.01 ± 0.51%). In the patient who had metastasis to the liver 3.5 years after initial operation and underwent five reoperations before death, the intervals until detection of recurrence tended to be shortened gradually. The Ki-67 labeling index varied with each operation, and tended to be higher at the time of reoperations than at the initial operation. Conclusion. The maximum tumor diameter, mitotic index, and Ki-67 labeling index were useful as an index of malignancy for gastric stromal tumor. The efficacy of surgical resection alone may be insufficient in patients with disseminated metastasis to the peritoneum.     

The way of submucosal invasion of superficial sm cancers]

Nineteen superficial sm cancers were studied as for their way of submucosal invasion. The materials were obtained either by colonoscopic polypectomy or by surgical operation. The following were concluded: 1. The ways of submucosal invasion can be classified into three. There is a special type of superficial early cancer which penetrate the mucosal muscle at one point and reaches the deeper layer linearly or show expansive growth at the submucosal layer. 2. The speed of submucosal invasion is either earlier (at the size around 5 mm), or slower (over 15 mm). 3. There are no significant difference in the way of submucosal invasion between IIa and IIc subclasses of superficial early cancers. That is one supporting evidence that there is no fundamental difference among subclasses of shapes of superficial early cancers. 4. One reason why the diagnosis of superficial cancers is difficult is that not a few superficial cancers undergo early morphological change (to sessile form) due to massive submucosal invasion.