Background Peritoneal recurrence of hepatocellular carcinoma (HCC) after hepatectomy occurs rarely, accounting for less than 1% of all recurrences. Reported causes of such dissemination include a history of rupture of the original HCC, needle biopsy or puncture treatment, and surgical procedures. There is no consensus on the optimal treatment strategy for peritoneal dissemination. There have been few reports on assisting resection of peritoneal dissemination by using indocyanine green (ICG) fluorescence. Case presentation A 57-year-old man underwent posterior sectionectomy for HCC. Six months later, computed tomography revealed multiple nodules suspected of indicating peritoneal dissemination. Various preoperative imaging studies demonstrated only four nodules, the doubling time of the tumors being rapid at 22 days. The nodules were therefore resected. ICG (0.5 mg/kg) was injected intravenously 2 days before the procedure, enabling identification of the nodules by their brightness in the operative field under near-infrared lighting. A total of eight lesions were detected during the procedure and resected, some of which had not been identified by preoperative imaging studies. We diagnosed peritoneal dissemination of HCC based on the pathological findings and their similarity to those of the original HCC. We concluded that the recurrences were likely attributable to exposure of the tumor to the serosa at the time of the original operation. Conclusions Although ICG fluorescence is useful for identifying peritoneal dissemination of HCC, attention should be paid to the difficulty in detecting deep lesions and occurrence of false positives.
There are several risk factors for acute cholecystitis (AC), including a history of cardiovascular disease. 1 Some researchers have reported that the incidence rate of AC occurring after cardiovascular surgery (CS) is 0.5%-6.0% and the mortality rate is 15%-42%. 2-9 Laurila et al 10 and Saito et al 11 reported that most cases of AC after CS are diagnosed as gangrenous cholecystitis, which can readily lead to sepsis, possibly in tandem with an unstable general health condition after CS. The reason for the development of AC after CS may be that many patients have low cardiac output to begin with, which triggers ischemia of the gallbladder mucosa, while extracorporeal circulation was associated with microcirculatory
Background Utility of the sentinel lymph node (SLN) biopsy in some malignancies has been reported, however, research on that of gallbladder cancer (GBC) is rare. The aim of this study is to investigate whether the concept of SLN is applicable to T2/3 GBC. Methods A total of 80 patients who underwent resection for gallbladder cancer were enrolled in this study. Patients with GBC were stratified into two groups based on the location of tumor, peritoneal-side (T2p or 3p) and hepatic-side (T2h or 3h) groups. We evaluated the relationship between cystic duct node (CDN) and downstream lymph node (LN) status. CDN was defined as a SLN in this study. Results Thirty-eight patients were classified into T2, including T2p (n = 18) and T2h (n = 20), and 42 patients into T3, including T3p (n = 22) andT3h (n = 20). The incidence of LN metastasis was significantly higher in hepatic-side than peritoneal-side in both T2 and T3 (P = 0.036 and 0.009, respectively). In T2, 14 T2p had negative CDN and downstream LN, however, three T2h had negative CDN and positive downstream LNs (defined as a skipped LN metastasis) (P = 0.043). In T3, patients with skipped LN metastasis were significantly higher in T3h (n = 11) than those in T3p (n = 2) (P<0.001). There was no recurrence of the local lymph node. Disease-free survival in the T2p and T3p were significantly better than those in the T2h and T3h (P = 0.005 and 0.025, respectively). Conclusion The concept of SLN can be applicable to T2p GBC, where the downstream LNs dissection can be omitted.
Portal vein embolization (PVE) is widely considered to improve the safety and extend the indication of major hepatectomy. There are various embolization materials and techniques in each facility. The safety and efficacy of absolute ethanol (EOH) in PVE were analyzed. Fifty-one patients who underwent PVE prior to major hepatectomy were enrolled in this study. Two types of embolization techniques were performed: transileocolic portal vein embolization (TIPE) and percutaneous transhepatic portal vein embolization (PTPE). The embolization material consisted of 20 mL of EOH and 2 mL of iodized oil. Multislice computed tomography (CT) scans were performed before and after PVE. The mean time interval between PVE and the follow-up CT scan was 16.3 6 5.0 days. The mean future liver remnant ratio to total liver (FLR%) significantly increased from 32.1% 6 7.6% to 43.5% 6 9.5% after PVE (P , 0.001). The mean hypertrophy ratio was 41.1% 6 34.5%. There were 3 major complications, subcutaneous hematoma in the TIPE group, hemobilia, and bile leakage in the PTPE group. Although the levels of aspartate transaminase and alanine transaminase increased dramatically after PVE, they subsequently returned to pre-PVE levels. There were no patients whose liver dysfunction was prolonged until hepatectomy. In conclusion, PVE using EOH is a safe and effective method to induce hypertrophy in the future remnant liver before major hepatectomy.
Background Extramedullary hematopoiesis is a compensatory response occurring secondary to inadequate bone marrow function and is occasionally observed in essential thrombocythemia (ET). This disease usually presents as multifocal masses in the paravertebral or intra-abdominal region; however, formation of a focal mass in the liver or spleen is rare. In addition, ET is characterized by increased platelet count and shows a tendency toward thrombosis and, occasionally, bleeding. Serious bleeding is common in ET patients, caused by the decrease in or abnormalities of von Willebrand factor (vWF) as a consequence of the precipitous rise in platelets. Therefore, strict management of platelet count using medication is crucial in patients with ET who require invasive procedures, especially splenectomy. Case presentation A 68-year-old man with ET was found to have an enlargement of a focal splenic tumor. Imaging findings revealed that the tumor was likely a hemangioma or hamartoma; however, the possibility of malignant disease could not be completely ruled out because of short-term tumor enlargement, and we conducted a splenectomy. The surgery was uneventful, but the patient presented with severe polycythemia and vWF abnormalities postoperatively, which resulted in bleeding from the drain insertion site and wound, epistaxis, and hemorrhoidal bleeding. Three months after discharge, polycythemia still persisted and the level of vWF gradually decreased. With a decrease in vWF, the patient suffered from an increased bleeding tendency. Therefore, the patient has been referred for bone marrow transplantation and is currently awaiting a suitable donor. Conclusions Extramedullary hematopoiesis should be listed as a differential diagnosis of focal enlarged splenic tumors, especially in patients with myeloproliferative disorders. Additionally, in splenectomy for ET patients, careful perioperative management taking into consideration the conflicting features of a tendency toward thrombus formation and bleeding is necessary.
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