AIM: To assess the safety of enhanced recovery after surgery(ERAS) program in gastrectomy and influences on nutrition state and insulin-resistance. METHODS: Our ERAS program involved shortening the fasting periods and...AIM: To assess the safety of enhanced recovery after surgery(ERAS) program in gastrectomy and influences on nutrition state and insulin-resistance. METHODS: Our ERAS program involved shortening the fasting periods and preoperative carbohydrate loading. Eighty gastrectomy patients were randomly assigned to either the conventional group(CG) or ERAS group(EG). We assessed the clinical characteristics and postoperative outcomes prospectively. The primary endpoint was noninferiority in timely discharge from the hospital within 12 d. Secondary endpoints were the incidence of aspiration at anesthesia induction, incidence of postoperative complications, health related quality of life(HRQOL) using the SF8 Health Survey questionnaire, nutrition state [e.g., albumin, transthyretin(TTR), retinal-binding protein(RBP), and transferrin(Tf)], the homeostasis model assessment-insulin resistance(HOMA-R) index, postoperative urine volume,postoperative weight change, and postoperative oral intake.RESULTS: The ERAS program was noninferior to the conventional program in achieving discharge from the hospital within 12 d(95.0% vs 92.5% respectively; 95%CI:-10.0%-16.0%). There was no significant difference in postoperative morbidity between the two groups. Adverse events such as vomiting and aspiration associated with the induction of general anesthesia were not observed. There were no significant differences with respect to postoperative urine volume, weight change, and oral intake between the two groups. EG patients with preoperative HOMA-R scores above 2.5 experienced significant attenuation of their HOMA-R scores on postoperative day 1 compared to CG patients(P = 0.014). There were no significant differences with respect to rapid turnover proteins(TTR, RBP and Tf) or HRQOL scores using the SF8 method.CONCLUSION: Applying the ERAS program to patients who undergo gastrectomy is safe, and improves insulin resistance with no deterioration in QOL.展开更多
A 72-year-old woman with a sigmoid colon cancer and a synchronous colorectal liver metastasis(CRLM),which involved the right hepatic vein(RHV)and the inferior vena cava(IVC),was referred to our hospital.The metastatic...A 72-year-old woman with a sigmoid colon cancer and a synchronous colorectal liver metastasis(CRLM),which involved the right hepatic vein(RHV)and the inferior vena cava(IVC),was referred to our hospital.The metastatic lesion was diagnosed as initially unresectable because of its invasion into the confluence of the RHV and IVC.After she had undergone laparoscopic sigmoidectomy for the original tumor,she consequently had 3 courses of modified 5-fluorouracil,leucovorin,and oxaliplatin(m FOLFOX6)plus cetuximab.Computed tomography revealed a partial response,and the confluence of the RHV and IVC got free from cancer invasion.After 3 additional courses of m FOLFOX6 plus cetuximab,preoperative percutaneous transhepatic portal vein embolization(PTPE)was performed to secure the future remnant liver volume.Finally,a right hemihepatectomy was performed.The postoperative course was uneventful.The patient was discharged from the hospital on postoperative day 13.She had neither local recurrence nor distant metastasis 18 mo after the last surgical intervention.This multidisciplinary strategy,consisting of conversion chemotherapy using FOLFOX plus cetuximab and PTPE,could contribute in facilitating curative hepatic resection for initially unresectable CRLM.展开更多
BACKGROUND: Early recurrence(ER) after hepatic resection(HR) is a poor prognostic factor for patients with hepatocellular carcinoma(HCC). This study aimed to identify the clinicopathological features, outcomes, and ri...BACKGROUND: Early recurrence(ER) after hepatic resection(HR) is a poor prognostic factor for patients with hepatocellular carcinoma(HCC). This study aimed to identify the clinicopathological features, outcomes, and risk factors for ER after HR for small HCC in order to clarify the reasons why ER is a worse recurrence pattern.METHODS: We retrospectively examined 130 patients who underwent HR for small HCC(≤30 mm). Recurrence was classified into ER(<2 years) and late recurrence(LR)(≥2 years). The clinicopathological features, outcomes, and risk factors for ER were analyzed by multivariate analysis.RESULTS: ER was observed in 39 patients(30.0%). The survival rate of the ER group was significantly lower than that of the LR group(P<0.005), and ER was an independent prognostic factor for poor survival(P=0.0001). The ER group had a significantly higher frequency(P=0.0039) and shorter interval(P=0.027) of development to carcinoma beyond the Milan criteria(DBMC) compared with the LR group, and ER was an independent risk factor for DBMC(P<0.0001). Multi-nodularity, non-simple nodular type, and microvascular invasion were independent predictors for ER(P=0.012, 0.010, and 0.019, respectively).CONCLUSIONS: ER was a highly malignant recurrence pattern associated with DBMC and subsequent poor survival after HR for small HCC. Multi-nodularity, non-simple nodular type, and microvascular invasion predict ER, and taking these factors into consideration may be useful for the decision of the treatment strategy for small HCC after HR.展开更多
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 describi...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.展开更多
Liver transplantation(LT)is a considerably effective treatment for patients with end-stage hepatitis B virus(HBV)-related liver disease.However,HBV infection often recurs after LT without prophylaxis.Since the1990s,th...Liver transplantation(LT)is a considerably effective treatment for patients with end-stage hepatitis B virus(HBV)-related liver disease.However,HBV infection often recurs after LT without prophylaxis.Since the1990s,the treatment for preventing HBV reinfection after LT has greatly progressed with the introduction of hepatitis B immunoglobulin(HBIG)and nucleos(t)ide analogues(NAs),resulting in improved patient survival.The combination therapy consisting of high-dose HBIG and lamivudine is highly efficacious for preventing the recurrence of HBV infection after LT and became the standard prophylaxis for HBV recurrence.However,mainly due to the high cost of HBIG treatment,an alternative protocol for reducing the dose and duration of HBIG has been evaluated.Currently,combination therapy using low-dose HBIG and NAs is considered as the most efficacious and cost-effective prophylaxis for post-LT HBV reinfection.Recently,NA monotherapy and withdrawal of HBIG from combination therapy,along with the development of new,potent high genetic barrier NAs,have provided promising efficacy,especially for low-risk recipients.This review summarizes the prophylactic protocol and their efficacy including prophylaxis of de novo HBV infection from anti-HBc antibody-positive donors.In addition,challenging approaches such as discontinuation of all prophylaxis and active immunity through hepatitis B vaccination are discussed.展开更多
AIM To examine the role of soluble fibrin monomer complex(SFMC) in the prediction of hypercoagulable state after gastroenterological surgery.METHODS We collected data on the clinical risk factors and fibrin-related ma...AIM To examine the role of soluble fibrin monomer complex(SFMC) in the prediction of hypercoagulable state after gastroenterological surgery.METHODS We collected data on the clinical risk factors and fibrin-related makers from patients who underwent gastroenterological surgery at Hiroshima University Hospital between April 1, 2014 and March 31, 2015. We investigated the clinical significance of SFMC, which is known to reflect the early plasmatic activation of coagulation, in the view of these fibrin related markers.RESULTS A total of 123 patients were included in the present study. There were no patients with symptomatic VTE. Thirty-five(28%) patients received postoperative anticoagulant therapy. In the multivariate analysis, a high SFMC level on POD 1 was independently associated with D-dimer elevation on POD 7(OR = 4.31, 95%CI: 1.10-18.30, P = 0.03). The cutoff SFMC level was 3.8 μg/ml(AUC = 0.78, sensitivity, 63%, specificity, 89%). The D-dimer level on POD 7 was significantly reduced in high-SFMC patients who received anticoagulant therapy in comparison to highSFMC patients who did not.CONCLUSION The SFMC on POD 1 strongly predicted the hypercoagulable state after gastroenterological surgery than the clinical risk factors and the other fibrin related markers.展开更多
Background: This study aimed to determine the safety and effectiveness of laparoscopy-assisted distal gastrectomy (LADG) after ESD. Methods: We reviewed patients with gastric cancer who underwent distal gastrectomy af...Background: This study aimed to determine the safety and effectiveness of laparoscopy-assisted distal gastrectomy (LADG) after ESD. Methods: We reviewed patients with gastric cancer who underwent distal gastrectomy after non-curative ESD from May 2000 to July 2010, and classified them into LADG-ESD and open distal gastrectomy (ODG) after non-curative ESD (ODG-ESD). In addition, we analyzed the standard LADG (LADG-standard) during the same period. We retrospectively analyzed surgical outcomes and survival in these 3 groups. Pathological results after gastrectomy were compared between the LADG-ESD and ODG-ESD;Results: Sixty-one patients underwent distal gastrectomy after non-curative ESD. No differences in overall survival were found between the LADG-ESD and ODG-ESD. The average duration to surgery after ESD was 42.4 days. Although the average surgical duration and average length of hospital stay after surgery were longer in the LADG-ESD than in the ODG-ESD, number of LN dissections was statistically identical in these 2 groups. Operative complications in the LADG-ESD (16.0%) was higher than that in the LADG-standard (3.8% - 8.2%) but similar to that in the ODG-ESD (13.9%). Conclusion: The present study suggests that LADG contributes to the effectiveness of the treatment of choice for non-curative endoscopic resection.展开更多
In this paper, we report an extremely rare case of an abscess that developed in the inguinal hernial sac after surgery for peritonitis. A 60-year-old man underwent laparoscopic low anterior resection for rectal cancer...In this paper, we report an extremely rare case of an abscess that developed in the inguinal hernial sac after surgery for peritonitis. A 60-year-old man underwent laparoscopic low anterior resection for rectal cancer. One day after this operation, peritoneal drainage and ileostomy were performed for rectal anastomotic leakage. Five days after the second operation, computed tomography revealed an abscess in the left inguinal hernial sac. Subsequently, hernioplasty and resection of the inflamed sac were performed.展开更多
A 61-year-old man presenting with abdominal pain and fever refractory to antibiotics underwent diagnostic laparoscopy and non-mass-forming isolated omental panniculitis was identified. He presented with left-upper-qua...A 61-year-old man presenting with abdominal pain and fever refractory to antibiotics underwent diagnostic laparoscopy and non-mass-forming isolated omental panniculitis was identified. He presented with left-upper-quadrant abdominal pain. Laboratory data and the CT findings suggested intraabdominal bacterial disease in the splenic flexure, which we treated with antibiotics and fasting. He clinically improved once, but later relapsed with abdominal pain migration to the left-lower-quadrant. CT re-examination revealed no inflammation in the splenic flexure, but attenuation of adipose tissue in the greater omentum. We partially extracted the greater omentum during diagnostic laparoscopy and diagnosed omental panniculitis and administered steroids. He improved and was discharged three days after starting oral prednisone and is recurrence-free with a close follow-up. The characteristic CT feature of omentum panniculitis is a high-density fatty mass, but we noted only an attenuation of adipose tissue in the greater omentum. Diagnositic laparoscopy is useful for diagnosing this condition.展开更多
文摘AIM: To assess the safety of enhanced recovery after surgery(ERAS) program in gastrectomy and influences on nutrition state and insulin-resistance. METHODS: Our ERAS program involved shortening the fasting periods and preoperative carbohydrate loading. Eighty gastrectomy patients were randomly assigned to either the conventional group(CG) or ERAS group(EG). We assessed the clinical characteristics and postoperative outcomes prospectively. The primary endpoint was noninferiority in timely discharge from the hospital within 12 d. Secondary endpoints were the incidence of aspiration at anesthesia induction, incidence of postoperative complications, health related quality of life(HRQOL) using the SF8 Health Survey questionnaire, nutrition state [e.g., albumin, transthyretin(TTR), retinal-binding protein(RBP), and transferrin(Tf)], the homeostasis model assessment-insulin resistance(HOMA-R) index, postoperative urine volume,postoperative weight change, and postoperative oral intake.RESULTS: The ERAS program was noninferior to the conventional program in achieving discharge from the hospital within 12 d(95.0% vs 92.5% respectively; 95%CI:-10.0%-16.0%). There was no significant difference in postoperative morbidity between the two groups. Adverse events such as vomiting and aspiration associated with the induction of general anesthesia were not observed. There were no significant differences with respect to postoperative urine volume, weight change, and oral intake between the two groups. EG patients with preoperative HOMA-R scores above 2.5 experienced significant attenuation of their HOMA-R scores on postoperative day 1 compared to CG patients(P = 0.014). There were no significant differences with respect to rapid turnover proteins(TTR, RBP and Tf) or HRQOL scores using the SF8 method.CONCLUSION: Applying the ERAS program to patients who undergo gastrectomy is safe, and improves insulin resistance with no deterioration in QOL.
文摘A 72-year-old woman with a sigmoid colon cancer and a synchronous colorectal liver metastasis(CRLM),which involved the right hepatic vein(RHV)and the inferior vena cava(IVC),was referred to our hospital.The metastatic lesion was diagnosed as initially unresectable because of its invasion into the confluence of the RHV and IVC.After she had undergone laparoscopic sigmoidectomy for the original tumor,she consequently had 3 courses of modified 5-fluorouracil,leucovorin,and oxaliplatin(m FOLFOX6)plus cetuximab.Computed tomography revealed a partial response,and the confluence of the RHV and IVC got free from cancer invasion.After 3 additional courses of m FOLFOX6 plus cetuximab,preoperative percutaneous transhepatic portal vein embolization(PTPE)was performed to secure the future remnant liver volume.Finally,a right hemihepatectomy was performed.The postoperative course was uneventful.The patient was discharged from the hospital on postoperative day 13.She had neither local recurrence nor distant metastasis 18 mo after the last surgical intervention.This multidisciplinary strategy,consisting of conversion chemotherapy using FOLFOX plus cetuximab and PTPE,could contribute in facilitating curative hepatic resection for initially unresectable CRLM.
文摘BACKGROUND: Early recurrence(ER) after hepatic resection(HR) is a poor prognostic factor for patients with hepatocellular carcinoma(HCC). This study aimed to identify the clinicopathological features, outcomes, and risk factors for ER after HR for small HCC in order to clarify the reasons why ER is a worse recurrence pattern.METHODS: We retrospectively examined 130 patients who underwent HR for small HCC(≤30 mm). Recurrence was classified into ER(<2 years) and late recurrence(LR)(≥2 years). The clinicopathological features, outcomes, and risk factors for ER were analyzed by multivariate analysis.RESULTS: ER was observed in 39 patients(30.0%). The survival rate of the ER group was significantly lower than that of the LR group(P<0.005), and ER was an independent prognostic factor for poor survival(P=0.0001). The ER group had a significantly higher frequency(P=0.0039) and shorter interval(P=0.027) of development to carcinoma beyond the Milan criteria(DBMC) compared with the LR group, and ER was an independent risk factor for DBMC(P<0.0001). Multi-nodularity, non-simple nodular type, and microvascular invasion were independent predictors for ER(P=0.012, 0.010, and 0.019, respectively).CONCLUSIONS: ER was a highly malignant recurrence pattern associated with DBMC and subsequent poor survival after HR for small HCC. Multi-nodularity, non-simple nodular type, and microvascular invasion predict ER, and taking these factors into consideration may be useful for the decision of the treatment strategy for small HCC after HR.
文摘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.
基金Supported by A Grant-in-Aid for the Research of Hepatitis and BSE from the Japanese Ministry of Health,Labour and Welfare
文摘Liver transplantation(LT)is a considerably effective treatment for patients with end-stage hepatitis B virus(HBV)-related liver disease.However,HBV infection often recurs after LT without prophylaxis.Since the1990s,the treatment for preventing HBV reinfection after LT has greatly progressed with the introduction of hepatitis B immunoglobulin(HBIG)and nucleos(t)ide analogues(NAs),resulting in improved patient survival.The combination therapy consisting of high-dose HBIG and lamivudine is highly efficacious for preventing the recurrence of HBV infection after LT and became the standard prophylaxis for HBV recurrence.However,mainly due to the high cost of HBIG treatment,an alternative protocol for reducing the dose and duration of HBIG has been evaluated.Currently,combination therapy using low-dose HBIG and NAs is considered as the most efficacious and cost-effective prophylaxis for post-LT HBV reinfection.Recently,NA monotherapy and withdrawal of HBIG from combination therapy,along with the development of new,potent high genetic barrier NAs,have provided promising efficacy,especially for low-risk recipients.This review summarizes the prophylactic protocol and their efficacy including prophylaxis of de novo HBV infection from anti-HBc antibody-positive donors.In addition,challenging approaches such as discontinuation of all prophylaxis and active immunity through hepatitis B vaccination are discussed.
文摘AIM To examine the role of soluble fibrin monomer complex(SFMC) in the prediction of hypercoagulable state after gastroenterological surgery.METHODS We collected data on the clinical risk factors and fibrin-related makers from patients who underwent gastroenterological surgery at Hiroshima University Hospital between April 1, 2014 and March 31, 2015. We investigated the clinical significance of SFMC, which is known to reflect the early plasmatic activation of coagulation, in the view of these fibrin related markers.RESULTS A total of 123 patients were included in the present study. There were no patients with symptomatic VTE. Thirty-five(28%) patients received postoperative anticoagulant therapy. In the multivariate analysis, a high SFMC level on POD 1 was independently associated with D-dimer elevation on POD 7(OR = 4.31, 95%CI: 1.10-18.30, P = 0.03). The cutoff SFMC level was 3.8 μg/ml(AUC = 0.78, sensitivity, 63%, specificity, 89%). The D-dimer level on POD 7 was significantly reduced in high-SFMC patients who received anticoagulant therapy in comparison to highSFMC patients who did not.CONCLUSION The SFMC on POD 1 strongly predicted the hypercoagulable state after gastroenterological surgery than the clinical risk factors and the other fibrin related markers.
文摘Background: This study aimed to determine the safety and effectiveness of laparoscopy-assisted distal gastrectomy (LADG) after ESD. Methods: We reviewed patients with gastric cancer who underwent distal gastrectomy after non-curative ESD from May 2000 to July 2010, and classified them into LADG-ESD and open distal gastrectomy (ODG) after non-curative ESD (ODG-ESD). In addition, we analyzed the standard LADG (LADG-standard) during the same period. We retrospectively analyzed surgical outcomes and survival in these 3 groups. Pathological results after gastrectomy were compared between the LADG-ESD and ODG-ESD;Results: Sixty-one patients underwent distal gastrectomy after non-curative ESD. No differences in overall survival were found between the LADG-ESD and ODG-ESD. The average duration to surgery after ESD was 42.4 days. Although the average surgical duration and average length of hospital stay after surgery were longer in the LADG-ESD than in the ODG-ESD, number of LN dissections was statistically identical in these 2 groups. Operative complications in the LADG-ESD (16.0%) was higher than that in the LADG-standard (3.8% - 8.2%) but similar to that in the ODG-ESD (13.9%). Conclusion: The present study suggests that LADG contributes to the effectiveness of the treatment of choice for non-curative endoscopic resection.
文摘In this paper, we report an extremely rare case of an abscess that developed in the inguinal hernial sac after surgery for peritonitis. A 60-year-old man underwent laparoscopic low anterior resection for rectal cancer. One day after this operation, peritoneal drainage and ileostomy were performed for rectal anastomotic leakage. Five days after the second operation, computed tomography revealed an abscess in the left inguinal hernial sac. Subsequently, hernioplasty and resection of the inflamed sac were performed.
文摘A 61-year-old man presenting with abdominal pain and fever refractory to antibiotics underwent diagnostic laparoscopy and non-mass-forming isolated omental panniculitis was identified. He presented with left-upper-quadrant abdominal pain. Laboratory data and the CT findings suggested intraabdominal bacterial disease in the splenic flexure, which we treated with antibiotics and fasting. He clinically improved once, but later relapsed with abdominal pain migration to the left-lower-quadrant. CT re-examination revealed no inflammation in the splenic flexure, but attenuation of adipose tissue in the greater omentum. We partially extracted the greater omentum during diagnostic laparoscopy and diagnosed omental panniculitis and administered steroids. He improved and was discharged three days after starting oral prednisone and is recurrence-free with a close follow-up. The characteristic CT feature of omentum panniculitis is a high-density fatty mass, but we noted only an attenuation of adipose tissue in the greater omentum. Diagnositic laparoscopy is useful for diagnosing this condition.
