Background
Benign multicystic peritoneal mesothelioma (BMPM) is a benign tumor that usually occurs in middle-aged females. Although several published studies have reported the occurrence of this ...tumor in the abdominal cavity, few have documented its development in the inguinal region.
Case presentation
We present a case of a 48-year-old female presenting with a bulge in her left inguinal region. Physical examination revealed a golf ball-sized nodule in the left inguinal region that could not be pushed back into the abdominal cavity. Contrast-enhanced computed tomography showed a multicystic tumor; therefore, the patient was diagnosed with inguinal hernia or hydrocele of the Nuck’s canal. We performed surgical resection and hernia repair using the mesh plug method. The resected specimen was 80 mm in length and contained a multicystic tumor. Pathological examination showed that the cyst wall was lined by a single layer of cuboidal to single layer squamous epithelium. Immunohistochemistry revealed positivity for calretinin in the epithelial cells, for which a diagnosis of BMPM was established. The patient returned to our hospital after 5 years with symptoms similar to the previous episode, but this time in the right inguinal region. Imaging studies showed a tumor in the right inguinal region with the same characteristics as the previous one. The patient underwent tumor resection and hernia repair using the same technique. The resected tumor was 45 mm in length and had characteristics similar to the previously resected tumor. The presence of calretinin and D2-40 on immunohistochemistry led to the diagnosis of BMPM. There was no recurrence of BMPM for 33 months after the secondary surgery.
Conclusions
Here we present the first report of metachronous BMPM occurring in bilateral inguinal canals. Although the pathogenesis of BMPM remains unclear, reactive changes have been suggested to cause tumors originating from the groin. The treatment of choice for BMPM is surgical resection. For diagnosis, pathological examination with immunostaining can be useful. The most appropriate postoperative follow-up for inguinal BMPM is controversial, and the accumulation of more inguinal BMPM cases is needed.
The number of elderly patients with hepatocellular carcinoma (HCC) has been increasing, but it remains unclear whether hepatectomy can be performed using the same criteria as in younger patients. ...Furthermore, the appropriate preoperative evaluation for hepatectomy in elderly patients is not yet clearly defined. Here, we investigated the applicability of preoperative assessment using the Controlling Nutritional Status (CONUT) score to help improve hepatectomy outcomes in elderly patients with HCC. This was a single-center retrospective analysis, and the study population comprised 64 consecutive patients who underwent hepatectomy for HCC between January 2012 and August 2016. We compared the preoperative assessment and perioperative outcomes between elderly (≥ 75 years old) and younger (< 75 years old) patients. A total of 61 patients were reviewed. Poor preoperative CONUT score was associated with a longer postoperative hospital stay in elderly patients undergoing hepatectomy for HCC. In addition, although elderly patients had similar perioperative outcomes to younger patients, the incidence of delirium was significantly higher, and univariate analysis confirmed that old age is a risk factor for delirium among the preoperative factors. Hepatectomy for HCC in the elderly can be safely performed with appropriate preoperative nutritional assessment using CONUT score and prevention of postoperative delirium. Preoperative nutritional assessment using the CONUT score was useful in predicting prolonged hospitalization for elderly hepatectomy with HCC.
Background
Laparoscopic surgery has reduced surgical morbidity and postoperative duration of hospital stay. Gas embolism is commonly known as a risk factor for all laparoscopic procedures. We report ...a case of severe cerebral infarction presumably caused by paradoxical CO
2
embolism in laparoscopic partial hepatectomy with an insufflation management system.
Case presentation
A male in his 60 s was diagnosed with recurrence of liver metastasis in the right hepatic lobe after laparoscopic lower anterior resection for rectal cancer. We performed laparoscopic partial hepatectomy with an AirSeal® under 10 mmHg of intra-abdominal pressure. During the surgery, the patient’s end-tidal CO
2
and percutaneous oxygen saturation dropped from approximately 40–20 mmHg and 100–90%, respectively, while the heart rate increased from 60 to 120 beats/min; his blood pressure remained stable. Postoperatively, the patient developed right hemiplegia and aphasia. Brain magnetic resonance imaging showed cerebral infarction in the broad area of the left cerebral cortex. Thereafter, transesophageal echocardiography revealed a patent foramen ovale, suggesting cerebral infarction due to paradoxical gas embolism.
Conclusions
A patent foramen ovale is found in approximately 15–20% of healthy individuals. While gas embolism is a rare complication of laparoscopic surgery, cerebral infarction must be considered a possible complication even if the intra-abdominal pressure is constant under 10 mmHg with an insufflation management system.
Humoral rejection after ABO-incompatible liver transplantation often causes graft loss and a life-threatening situation. We used rituximab, which can eliminate B cells highly selectively, as an ...additional therapy for ABO-incompatible living-related liver transplantation.
Patient 1 was a 1-year-old girl with biliary atresia. Her blood type was O, and the donor's was A. She underwent two plasma exchanges before liver transplantation and had triple immunosuppressants (mycophenolate mofetil, tacrolimus, and methylprednisolone). She was diagnosed with humoral rejection by needle biopsy on postoperative day 6. Rituximab was used for 3 days at 375, 187, and 187 mg/m(2) and successfully reduced the antibody titer, transaminase, and CD19(+) cells count in peripheral blood lymphocytes. The patient has not had any severe rejection, infection, or serious complications 2 years posttransplantation. Patient 2 was a 42-year-old woman with primary biliary cirrhosis. The blood type was O, and the donor's was B. She received three plasma exchanges, triple immunosuppressants, splenectomy, intraarterial anticoagulant therapy, and rituximab (375 mg/m(2) immediately after transplantation). The titer and CD19(+) cells count remained persistently low throughout the recovery course. She did not develop humoral rejection 1 year after transplantation.
Rituximab efficiently reduces anti-ABO antibody titer by selectively eliminating B cells and is safe and effective against humoral rejection after ABO-incompatible liver transplantation.
Purpose
To compare the surgical outcomes of ileostomy vs. transverse colostomy and investigate which is more suitable for a diverting stoma.
Methods
We assessed stoma-related complications and ...surgical outcomes, retrospectively, for 146 patients who underwent laparoscopic colorectal surgery with a temporary loop ileostomy or transverse colostomy. Complications after secondary stoma closure surgery were also analyzed.
Results
After the primary surgery, the incidence of prolapse was significantly higher in the transverse colostomy group, whereas high-output stoma and skin irritation were seen more frequently in the ileostomy group. The median interval to stoma closure was shorter in the ileostomy group than in the transverse colostomy group (144 vs. 196 days). After secondary closure surgery, the incidence of wound infection was significantly higher in the transverse colostomy group than in the ileostomy group. None of the patients in the ileostomy group had severe complications. The median postoperative hospital stay was significantly shorter in the ileostomy group than in the transverse colostomy group (10 vs. 13 days).
Conclusions
The findings of this study suggest that ileostomy should be the procedure of choice for short-term temporary diverting stoma, but that transverse colostomy is more appropriate for patients who require a long-term or permanent stoma.
To evaluate the effects of a portocaval shunt on the decrease of excessive portal flow for the prevention of sinusoidal microcirculatory injury in extremely small-for-size liver transplantation in ...pigs.
The right lateral lobe of pigs, i.e. the 25% of the liver, was transplanted orthotopically. The pigs were divided into two groups: graft without portocaval shunt (n = 11) and graft with portocaval shunt (n = 11). Survival rate, portal flow, hepatic arterial flow, and histological findings were investigated.
In the group without portocaval shunt, all pigs except one died of liver dysfunction within 24 h after transplantation. In the group with portocaval shunt, eight pigs survived for more than 4 d. The portal flow volumes before and after transplantation in the group without portocaval shunt were 118.2+/-26.9 mL/min/100 g liver tissue and 270.5+/-72.9 mL/min/100 g liver tissue, respectively. On the other hand, in the group with portocaval shunt, those volumes were 124.2+/-27.8 mL/min/100 g liver tissue and 42.7+/-32.3 mL/min/100 g liver tissue, respectively (P<0.01). As for histological findings in the group without portocaval shunt, destruction of the sinusoidal lining and bleeding in the peri-portal areas were observed after reperfusion, but these findings were not recognized in the group with portocaval shunt.
These results suggest that excessive portal flow is attributed to post transplant liver dysfunction after extreme small-for-size liver transplantation caused by sinusoidal microcirculatory injury.
Foley balloons have been used to secure emergency hemostasis for cardiac or vascular injuries since the 1960s. However, using a single large balloon may have drawbacks, such as insufficient ...hemostasis and blood flow impairment. We have encountered 3 major intraoperative laceration cases since 2011. The laceration sites (lengths) were at the inferior vena cava (2.5 cm), main pulmonary artery (2 cm), and right ventricle (5 cm). We successfully managed these patients by using multiple small (10F-14F, half-inflated) Foley balloons. Using small Foley balloons may overcome the drawbacks of using 1 large balloon and effectively manage large lacerations.
Situs inversus totalis (SIT) is a rare anatomic anomaly, occurring once in every 3000-5000 births in Japan. A 72-year-old woman with SIT visited our hospital for the investigation of fecal occult ...blood. Colonoscopy revealed a type-2 tumor in the ascending colon, and the preoperative diagnosis based on the 8th UICC TNM classification was cT3N0M0 cStage IIA. We planned a laparoscopic right colectomy procedure with medial approach. The surgery was performed using five ports. The main surgeon stood between the patient's legs, while the assistants stood on the right side of the patient as opposed to the usual positioning where they stand on the left side. The operating time was 163 min. and the blood loss was 18 g. She was discharged on the 9th postoperative day, without postoperative complications. Histopathological examination revealed moderately differentiated adenocarcinoma, pT4bN0M0 pStage IIC. Preoperative assessment of the anatomical position and vascular malformations, using three-dimensional computed tomography, was essential for our safe surgical intervention. Furthermore, our co-axial technique and positioning the surgeon between the patient's legs enabled us to perform the procedure in the same way as a normal right-sided colectomy with a medial approach.
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