Outcomes of Damage Control Surgery for Abdominal Trauma Evaluated Using the Trauma and Injury Severity Score and Lethal Triad in a Single Institution

In trauma management, damage control surgery is an effective approach to decrease the incidence of preventable trauma death. In this study, we aimed to investigate the survival outcomes and clinical factors in patients undergoing damage control surgery for severe abdominal trauma, in relation to trauma severity based on the trauma and injury severity score and lethal triad (hypothermia, metabolic acidosis, and coagulopathy), to assess the indicators of mortality and criteria for performing damage control surgery. Fifteen patients with severe abdominal trauma underwent damage control surgery from January 2011 to September 2017. We compared the short-term outcomes and perioperative factors associated with the trauma and injury severity score and the lethal triad between survivors and non-survivors. Of the 15 included patients, eight (53.3%) survived and seven (46.7%) died. No preventable deaths occurred. The patient characteristics, including age, sex, and mechanism of injury were not related to survival. The injury severity score (p = 0.035) and abbreviated injury scale score of the head (p = 0.005) were significantly higher among the nonsurvivors than among the survivors. Of the lethal triad, the incidence of metabolic acidosis was significantly higher in the non-survivors (p < 0.050). This study found that head injury and metabolic acidosis are predictors of mortality. These indications provide a practical basis for determining whether to use damage control surgery and postoperative management

Atraumatic Femoral Insufficiency Fracture in Postmenopausal Women Taking Bisphosphonate

The patient was 85-year-old woman. Five years and 8 months previously, bisphosphonate was prescribed for osteoporosis at a local clinic. Deformity of the thigh occurred when she tried to stand after sitting. X-ray findings revealed a transverse fracture of the right femoral diaphysis. Intramedullary nailing of the right femur was performed. Bone union was slightly delayed, but it was eventually achieved. Bisphosphonates have been reported to severely suppress bone turnover, resulting in the occurrence of fractures at the diaphysis or metaphysis of the femur. This type of fracture is characteristically induced by minor trauma and usually shows a simple transverse fracture. Bone union is delayed and these patients complain of prodromal symptoms. Because our case met all of the above criteria, it was concluded that the cause of her fracture was severely suppressed bone turnover (SSBT). We treated a patient who had a pathologic fracture associated with bisphosphonate therapy. Careful follow-up will be required, because it has been reported that such fractures can also occur on the contralateral side

Plasma Free Amino Acid Profiling of Five Types of Cancer Patients and Its Application for Early Detection

BACKGROUND: Recently, rapid advances have been made in metabolomics-based, easy-to-use early cancer detection methods using blood samples. Among metabolites, profiling of plasma free amino acids (PFAAs) is a promising approach because PFAAs link all organ systems and have important roles in metabolism. Furthermore, PFAA profiles are known to be influenced by specific diseases, including cancers. Therefore, the purpose of the present study was to determine the characteristics of the PFAA profiles in cancer patients and the possibility of using this information for early detection. METHODS AND FINDINGS: Plasma samples were collected from approximately 200 patients from multiple institutes, each diagnosed with one of the following five types of cancer: lung, gastric, colorectal, breast, or prostate cancer. Patients were compared to gender- and age- matched controls also used in this study. The PFAA levels were measured using high-performance liquid chromatography (HPLC)-electrospray ionization (ESI)-mass spectrometry (MS). Univariate analysis revealed significant differences in the PFAA profiles between the controls and the patients with any of the five types of cancer listed above, even those with asymptomatic early-stage disease. Furthermore, multivariate analysis clearly discriminated the cancer patients from the controls in terms of the area under the receiver-operator characteristics curve (AUC of ROC >0.75 for each cancer), regardless of cancer stage. Because this study was designed as case-control study, further investigations, including model construction and validation using cohorts with larger sample sizes, are necessary to determine the usefulness of PFAA profiling. CONCLUSIONS: These findings suggest that PFAA profiling has great potential for improving cancer screening and diagnosis and understanding disease pathogenesis. PFAA profiles can also be used to determine various disease diagnoses from a single blood sample, which involves a relatively simple plasma assay and imposes a lower physical burden on subjects when compared to existing screening methods

A rare case of a spontaneously ruptured secondary hepatic malignant lymphoma

Abstract Background Although secondary liver involvement of the lymphoma is common and occurs in 50% of patients with non-Hodgkin’s lymphoma, liver tumor rupture in malignant lymphoma is extremely rare. We report a case of a spontaneously ruptured secondary liver involvement of non-Hodgkin’s lymphoma that was successfully treated with transcatheter arterial embolization (TAE) to obtain hemostasis, and subsequent hepatectomy and systemic chemotherapy. To the best of our knowledge, this is only the second reported case of a ruptured hepatic lymphoma. Case presentation A 74-year-old man with sudden-onset right shoulder and upper quadrant pain was transferred to our hospital via an ambulance. His vital signs were stable. Contrast-enhanced computed tomography showed a large hypo-enhancing tumor (94 × 81 mm) in the posterior segment of the liver, with intratumoral extravasation and a 12 × 10 mm daughter tumor in segment 5 of the liver. Hemoperitoneum due to rupture of hepatocellular carcinoma with intratumoral hemorrhage was suspected, although the serum alpha-fetoprotein and protein induced by vitamin K absence-II levels were within normal range. TAE was used for hemostasis. Extended posterior segmentectomy including tumor resection in segment 5 was performed on day 23 after embolization. The postoperative course was uneventful. Pathological examination of the resected specimens revealed that the ruptured tumor was diffuse large B-cell lymphoma. Postoperative fluorodeoxyglucose positron emission tomography-computed tomography showed uptake in the left parotid gland, pancreas, and thoracic vertebra. Based on these findings, the final diagnosis was a ruptured secondary hepatic malignant lymphoma. Complete remission was achieved with chemotherapy. He remains alive 30 months after hepatectomy without evidence of relapse. Conclusions We report the first case describing a hepatic tumor rupture as the first presentation of a primary or secondary hepatic malignant lymphoma. The patient was successfully treated with TAE, hepatectomy, and subsequent systemic chemotherapy for non-Hodgkin’s lymphoma

Celiac axis stenosis due to median arcuate ligament compression in a patient who underwent pancreatoduodenectomy; intraoperative assessment of hepatic arterial flow using Doppler ultrasonography: a case report

Abstract Background Celiac axis stenosis due to compression by the median arcuate ligament has been reported in patients undergoing pancreaticoduodenectomy; it leads to the development of major collateral pathways that feed the hepatic artery. Dividing these important collaterals during pancreaticoduodenectomy can cause ischemic complications which may lead to a high mortality rate. To prevent these complications, it is necessary to assess intrahepatic arterial flow. Case presentation A 71-year-old Japanese man with anorexia was referred to us for the treatment of alcoholic chronic pancreatitis. Computed tomography revealed a pancreatic head tumor with a calculus, associated with the dilatation of the main pancreatic duct and intrahepatic bile duct. Three-dimensional imaging demonstrated focal narrowing in the proximal celiac axis due to median arcuate ligament compression and a prominent gastroduodenal artery that fed the common hepatic artery. The preoperative diagnosis was alcoholic chronic pancreatitis with common bile duct obstruction and celiac axis stenosis due to median arcuate ligament compression. Pancreaticoduodenectomy with median arcuate ligament release was scheduled. Before the division of the median arcuate ligament, the peak flow velocity and resistive index of his intrahepatic artery measured with Doppler ultrasonography decreased from 37.7 cm/second and 0.510, respectively, to 20.6 cm/second and 0.508 respectively, when his gastroduodenal artery was clamped. However, these values returned to baseline levels after the division of the median arcuate ligament. These findings suggested that pancreaticoduodenectomy could be performed safely. Our patient was discharged on postoperative day 17 without significant complications. Conclusion The intraoperative quantitative evaluation of intrahepatic arterial blood flow using Doppler ultrasonography was useful in a patient who underwent pancreaticoduodenectomy, who had celiac axis stenosis due to compression by the median arcuate ligament

Synchronous double primary hepatic cancer consisting of hepatocellular carcinoma and cholangiolocellular carcinoma: a case report

Abstract Background The incidence of synchronous double primary hepatic cancers is extremely low. Cholangiolocellular carcinoma is also a rare disease. Case presentation A 58-year-old Japanese man was referred to our hospital for the treatment of multiple liver tumors revealed on computed tomography scans. He was hepatitis B and C positive and had undergone hemodialysis for 9 years due to chronic renal failure. Computed tomography scans revealed two hepatic tumors (each ≤ 1.0 cm in diameter) in segments 3 and 7. The preoperative diagnosis was multiple hepatocellular carcinomas. He underwent partial resections of his liver. The resected specimens revealed that the tumors in segments 3 and 7 were well-defined lesions of 8.0 mm and 14.0 mm, respectively. Pathological and immunohistochemical examinations confirmed the tumor in segment 3 to be a cholangiolocellular carcinoma and the tumor in segment 7 to be a hepatocellular carcinoma. Chronic inflammation could contribute to the different types of primary hepatic cancers. It may also give rise to various combinations of synchronous double primary hepatic cancer in patients with chronic liver disease. Conclusions We describe the sixth case of synchronous double primary hepatic cancers consisting of hepatocellular carcinoma and cholangiolocellular carcinoma in chronic damaged liver and review the literature. In patients with chronic liver disease, careful surveillance with imaging studies should be mandatory as various types of primary hepatic cancers could develop

Hepatocellular carcinoma and focal nodular hyperplasia of the liver in a glycogen storage disease patient

Glycogen storage disease type Ia (GSD-Ia; also called von Gierke disease) is an autosomal recessive disorder of carbohydrate metabolism caused by glucose-6-phosphatase deficiency. There have been many reports describing hepatic tumors in GSD patients; however, most of these reports were of hepatocellular adenomas, whereas there are only few reports describing focal nodular hyperplasia (FNH) or hepatocellular carcinoma (HCC). We report a case with GSD-Ia who had undergone a partial resection of the liver for FNH at 18 years of age and in whom moderately differentiated HCC had developed. Preoperative imaging studies, including ultrasonography, dynamic computer tomography (CT) and magnetic resonance imaging, revealed benign and malignant features. In particular, fluorodeoxyglucose-positron emission tomography (FDG-PET)/CT revealed the atypical findings that FDG accumulated at high levels in the non-tumorous hepatic parenchyma and low levels in the tumor. Right hemihepatectomy was performed. During the perioperative period, high-dose glucose and sodium bicarbonate were administered to control metabolic acidosis. He had multiple recurrences of HCC at 10 mo after surgery and was followed-up with transcatheter arterial chemoembolization. The tumor was already highly advanced when it was found by chance; therefore, a careful follow-up should be mandatory for GSD-I patients as they are at a high risk for HCC, similar to hepatitis patients

A novel model for predicting posthepatectomy liver failure based on liver function and degree of liver resection in patients with hepatocellular carcinoma

Background The permissible liver resection rate for preventing posthepatectomy liver failure (PHLF) remains unclear. We aimed to develop a novel PHLF-predicting model and to strategize hepatectomy for hepatocellular carcinoma (HCC). Methods This retrospective study included 335 HCC patients who underwent anatomical hepatectomy at eight institutions between 2013 and 2017. Risk factors, including volume-associated liver-estimating parameters, for PHLF grade B–C were analyzed in a training set (n = 122) via multivariate analysis, and a PHLF prediction model was developed. The utility of the model was evaluated in a validation set (n = 213). Results Our model was based on the three independent risk factors for PHLF identified in the training set: volume-associated indocyanine green retention rate at 15 min, platelet count, and prothrombin time index (the VIPP score). The areas under the receiver operating characteristic curve of the VIPP scores for severe PHLF in the training and validation sets were 0.864 and 0.794, respectively. In both sets, the VIPP score stratified patients at risk for severe PHLF, with a score of 3 (specificity, 0.92) indicating higher risk. Conclusion Our model facilitates the selection of the appropriate hepatectomy procedure by providing permissible liver resection rates based on VIPP scores.This research was supported by the Japan Agency for Medical Research and Development (AMED, grant number JP19fk0210051) and the Japanese Society for the Promotion of Science (JSPS KAKENHI, grant number JP18K08706