Hepatic Angiomyolipoma with Minimal Intratumoral Fat Content

We report a rare case of hepatic angiomyolipoma with minimal fat content. The low fat content led to an incorrect preoperative diagnosis. A 38-year-old man who was a carrier of hepatitis B virus infection incidentally presented with a hepatic tumor. His serum alpha-fetoprotein level was normal. Ultrasonography revealed a well-circumscribed, heterogeneous hypoechoic nonencapsulated liver tumor measuring 34 × 24 mm. Precontrast computed tomography (CT) did not reveal fatty attenuation in the lesion. Contrast-enhanced CT revealed a hypervascular nonencapsulated tumor in the arterial phase and moderate washing out of the contrast medium in the portal phase. A hypervascular tumor was observed on CT hepatic arteriography, and complete washing out of the contrast medium on CT during arterial portography. These findings are compatible with hepatocellular carcinoma. The tumor exhibited low signal intensity on T1-weighted images and high signal intensity on T2-weighted images; no hypointensity was observed on fat suppression images. The patient underwent left hemihepatectomy because of a preoperative diagnosis of hepatocellular carcinoma. The histopathological diagnosis was a hepatic angiomyolipoma with 5% fat content. Low fat content makes the diagnosis of this condition difficult. The absence of serum tumor markers and the presence of a nonencapsulated hypervascular tumor may facilitate the accurate preoperative diagnosis of hepatic angiomyolipomas that have a low fat content and mimic hepatocellular carcinoma

Longitudinal study on quality of life and on anxiety factors in living donors before and after adult-to-adult liver transplantation

生体肝移植ドナー10例の術前から術後3ヶ月までの身体回復過程を縦断的に観察し, 更にQOL調査票および不安尺度を用いて身体面および心理面での経時的変化を分析し, 以下の結論を得た. 1. ドナーの臨床的所見・データは術後1ヶ月目でほぼ術前まで回復したが, 身体的QOLは3ヶ月経っても十分には回復せず, 日常生活や活動が制限されていた. そのため, 術前から術後の生活をイメージできるような情報提供やカウンセリングが必要と思われた. 2. ドナーは本来健康なため順調に回復する場合が多いが, 術後疼痛は3ヶ月経っても存在し, 疼痛によって心身両面に影響を受けていた. そのため, 適切な疼痛コントロールおよび, より侵襲の少ない手術手技の工夫などが今後の課題としてあげられた. 3. ドナーは術前後を通して, 自分のこと以上にレシピエントに関する事柄に対して多くの不安を感じていた. したがって, 医療者は適時レシピエントに関する情報提供を行い, ドナーの不安軽減に努めることが大切と思われた.We observed the recovery process in 10 living donors for liver transplantation up to 3 months after the operation, and we also analyzed physical and mental changes in the donors using questionnaires on quality of life (QOL) and anxiety tests. The following results were obtained. 1. The clinical status of the donors had almost recovered to the preoperative level at one month after the operation, but physical QOL had not recovered to the preoperative QOL level even at 3 months after the operation. The donors still had limitations in their daily lives and activities at 3 months postoperatively. These findings indicate the need for information on postoperative life and counseling to prepare for postoperative life to be provided to donors before the operation. 2. Living donors for liver transplantation are in good general health and therefore usually recover smoothly after the operation. However, it was found the donors experienced pain even 3 months after the operation and that the pain affected both their physical and mental conditions. Therefore, consideration must be given to appropriate pain control and to establishing less-invasive surgical procedures. 3. The donors felt more anxiety for the recipients than for themselves before and after the operation. Therefore, medical staff should make efforts to provide information about the recipient to the donor and reduce the donor's level of anxiety

Laparoscopic cholecystectomy for acute cholecystitis in a patient with left-sided gallbladder: a case report

Abstract Background Left-sided gallbladder is a relatively rare anatomical variation that is frequently associated with a biliary system anomaly. Here, we describe a case of left-sided gallbladder with acute cholecystitis treated by laparoscopic cholecystectomy. Case presentation An 86-year-old man with acute upper abdominal pain was admitted to our hospital. Computed tomography demonstrated that the gallbladder was centrally dislocated and the wall enhancement was discontinued. Magnetic resonance cholangiopancreatography showed that the gallbladder wall was thickened and abnormally swollen. A laparoscopic cholecystectomy was performed. The round ligament was attached to the right side of the gallbladder, and the left-sided gallbladder was diagnosed by intraoperative findings. The patient was discharged 5 days after surgery without postoperative complications. Conclusions A flexible and optimal port site should be inserted in cases of left-sided gallbladder with acute cholecystitis. An assessment of the extra- and intrahepatic biliary system is essential to avoid biliary injury in cases of left-sided gallbladder with acute cholecystitis

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

Divergence of postoperative recovery process and patient QOL based on the surgical site in patients undergoing liver tumor resection

本研究は,肝腫瘍に対する手術創部位によって患者の術後回復過程やQOLに,どのような相違が認められるかを明らかにすることを目的とした.対象は,肝腫瘍切除術を受けた患者17名で,手術創の違いにより開胸+開腹群,開腹群の二群に分けて検討を行った.データ収集の方法は,診療記録と「身体的内容」「心理的内容」「社会的内容」から構成された質問紙調査により行った. その結果,歩行開始時期は開胸+開腹群が開腹群に比べ有意に遅延し,膀胱カテーテル抜去時期やPatient controlled epidural analgesia(PCEA)装着期間,術後～退院までの平均在院日数においても遅延する傾向がみられた.また,創部痛や食欲出現時期においても開胸+開腹群が開腹群に比べ有意に遅延し,術後の生活様式の変化の有無においても有意差を認めた. 従って,医療者は手術創部位によって患者の術後経過に違いが認められることを理解した上で適切なケアや指導を行っていくとともに,患者にとって手術を受けて良かったと思えるような支援を行っていく必要があることが示唆された.The purpose of this study was to clarify the kind of divergence observed in terms of the preoperative recovery process and QOL of patients, depending on the location of the surgical wound for liver tumors. The subjects consisted of 17 patients that underwent resection for liver tumors, and an analysis was carried out by dividing them into two groups, the thoracotomy plus laparotomy group and the laparotomy group, based on the difference in their surgical wounds. Data were collected by browsing through the clinical records and by a questionnaire consisting of "physical content," "psychological content," and "social content." As a result, the period of gait initiation was found to be significantly delayed for the thoracotomy plus laparotomy group compared to the laparotomy group, and a tendency to be delayed was also observed during urethral catheter suture removal, the period of equipping PCEA, and the average hospital days following surgery until discharge. Moreover, wound pain and the recovery of the patient's appetite were significantly delayed in the thoracotomy plus laparotomy group compared to the laparotomy group, and a significant difference was also observed in the presence of postoperative lifestyle change. Therefore, it was suggested that it is necessary for medical staff to carry out appropriate care and guidance with the understanding that there are differences in a patient's postoperative recovery depending on the location of the surgical wound, and along with that, to provide sufficient support to enable the patients to have a positive approach to undergoing surgery

The gastric carcinosarcoma with severe venous invasion: a case report

Abstract Background Gastric carcinosarcoma with severe venous invasion is extremely rare, and to the best of our knowledge, this is the first reported case. Case presentation A 79-year-old man visited the Onomichi General Hospital following abnormal upper gastrointestinal series findings. Laboratory data demonstrated no anemia, and the serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels were not elevated. Endoscopy identified a Borrmann type III lesion in the cardiac end of the stomach. Abdominal contrast-enhanced computerized tomography (CT) indicated that the lesser curvature of the stomach wall was modestly enhanced with bulky lymph nodes. Pathological biopsy examination identified a group 5, papillary adenocarcinoma. We diagnosed advanced gastric cancer with bulky lymph nodes (cT4aN3M0, cStage IIIC). Following neoadjuvant chemotherapy, the patient underwent open total gastrectomy with D2 lymph node dissection. Histopathologically, the tumor consisted of two components: a tubular adenocarcinoma and a sarcoma. The tumor cells were mainly intravenous and were not detected in the gastric wall stroma; this resulted in a venous invasion. Immunohistochemical analysis revealed that the tumor was positive for vimentin and partly positive for desmin and cytokeratin CAM5.2. We diagnosed a true gastric carcinosarcoma with severe venous invasion. Abdominal CT 2 months after surgery showed a low density area in the liver, suggesting metastasis. Conclusions Carcinosarcomas with lymph node metastasis are sometimes reported, but progression into the vasculature is very rare. We present a case of carcinosarcoma with unusual progression characteristics

Complete spontaneous necrosis of hepatocellular carcinoma confirmed on resection: A case report

Introduction: Complete spontaneous necrosis of hepatocellular carcinoma (HCC) without any pretreatment or angiography is rare. We present a rare case of spontaneous complete necrosis of HCC, as confirmed after hepatectomy. Presentation of case: The patient, a 74-year-old man with a history of alcoholic hepatitis, was referred to our hospital for confirmation of suspected HCC. In March 2015, abdominal ultrasonography detected a low echoic mass in segment 8 (S8) of the liver. Contrast-enhanced computed tomography (CT) imaging revealed interval growth of this tumor and showed that the tumor was well enhanced in the arterial phase and washed out in the portal and delayed phases. The serum alpha-fetoprotein level was elevated at 30.8 ng/mL and the percentage of the L3 isoform was 25.5%. Two months later, CT imaging showed that the tumor was of low density and had decreased in size; no contrast enhancement of the tumor was seen. Spontaneous necrosis of the HCC was considered; however, as we could not exclude viable malignant cells in the tumor, we performed S8 segmentectomy of the liver. The resected tumor specimen had a thick fibrous capsule. Histopathological findings showed only granulation and necrotic tissue accompanied by bleeding and hemosiderosis. No viable tumor cells were observed. The serum alpha-fetoprotein level returned to the normal range one month after surgery. Discussion: If spontaneous regression has occurred, there is a possibility of HCC recurrence and of remnant viable tumor cells. Conclusion: We present a rare case of complete spontaneous necrosis of HCC and strongly recommended surgical intervention

A biologically active lipid, thromboxane, as a regulator of angiogenesis and lymphangiogenesis

Thromboxane (TX) and prostaglandins are metabolites of arachidonic acid, a twenty-carbon unsaturated fatty acid, and have a variety of actions that are exerted via specific receptors. Angiogenesis is defined as the formation of new blood vessels from pre-existing vascular beds and is a critical component of pathological conditions, including inflammation and cancer. Lymphatic vessels play crucial roles in the regulation of interstitial fluid, immune surveillance, and the absorption of dietary fat from the intestine; and they are also involved in the pathogenesis of various diseases. Similar to angiogenesis, lymphangiogenesis, the formation of new lymphatic vessels, is a critical component of pathological conditions. The TP-dependent accumulation of platelets in microvessels has been reported to enhance angiogenesis under pathological conditions. Although the roles of some growth factors and cytokines in angiogenesis and lymphangiogenesis have been well characterized, accumulating evidence suggests that TX induces the production of proangiogenic and prolymphangiogenic factors through the activation of adenylate cyclase, and upregulates angiogenesis and lymphangiogenesis under disease conditions. In this review, we discuss the role of TX as a regulator of angiogenesis and lymphangiogenesis, and its emerging importance as a therapeutic target

Value of endoscopic ultrasonography in the observation of the remnant pancreas after pancreatectomy.

BackgroundEndoscopic ultrasonography (EUS) is proven to be a more specific and sensitive method for detecting pancreatic lesions. However, usefulness of EUS after pancreatectomy has not been reported. This study aimed to evaluate the observational capability of EUS for the remnant pancreas (RP) after pancreatectomy.Patient and methodsThis single-center, retrospective study enrolled 395 patients who underwent pancreatectomy at Onomichi General Hospital between December 2002 and March 2016, 45 patients who underwent EUS for RP were included for analysis. We evaluated the usefulness of EUS for RP using logistic regression analysis.ResultsComplete observation of the RP was done in 42 patients (93%). In the initial surgical procedure, 21 patients underwent pancreaticoduodenectomy (PD), and 24 patients underwent distal pancreatectomy (DP). PD and DP were observed in 85% (18/21) and 100% (24/24) cases, respectively. A comparison of the detection capability of EUS and contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) showed that EUS was significantly superior to contrast-enhanced CT or MRI (p ConclusionsEUS was able to observe the RP in almost all cases. In addition, the detection capability of EUS was significantly superior to those of CT or MRI. We recommend that all patients with RP should undergo EUS, and a longer follow-up must be performed