Differentiation of gallbladder adenomyomatosis from early-stage gallbladder cancer before surgery

Backgrounds/Aims

This study aimed to compare the perioperative and clinical outcomes in patients undergoing laparoscopic cholecystectomy for gallbladder adenomyomatosis (GBA) or early-stage gallbladder cancer (GBC).

Methods

The perioperative and clinical outcomes of 194 patients diagnosed with GBA and 30 patients diagnosed with GBC who underwent laparoscopic cholecystectomy in our institution from January 2011 to December 2017 were retrospectively compared.

Results

There were no significant differences between the GBA and GBC groups in sex (male:female ratio 1.0:0.8 vs. 1.0:0.7, p=0.734), BMI (23.9±3.4 vs. 24.0±3.8 kg/m², p=0.916), or preoperative liver function tests. Patients in the GBC group were significantly older (50.5±14.1 vs. 65.9±10.6 years, p<0.001) and had a higher ASA grade (40.3 vs. 63.4% grade II or III, p=0.043) than patients in the GBA group. Although there was no significant difference in preoperative diagnostic methods (p=0.442), the GBC group showed a significantly higher rate of misdiagnosis on preoperative imaging compared with postoperative histopathologic findings (30.9% vs. 53.3%, p=0.011). There were significantly more patients with gallstones in the GBA group than in the GBC group (68.6% vs. 40.0%, p=0.004).

Conclusions

In older patients hospitalized for biliary colic without gallstones but with a thickened gallbladder wall with inflammation on preoperative diagnostic exam, the possibility of early-stage GBC should be considered.

Recurrent thrombosis of splanchnic and lower extremity arteries with essential thrombocythemia

Essential thrombocythemia is a myeloproliferative neoplasm characterized by platelet aggregation and thrombosis. Clinically, essential thrombocythemia increases the risk of both thrombosis and bleeding. Essential thrombocythemia is more involved in micro- and small-sized arteries than in large arteries. Many essential thrombocythemia patients exhibit various symptoms, including microvascular thrombosis with acute coronary disease, digital ischemia, and transient ischemic attack. This study reports a rare case of recurrent thrombosis in relatively large vessels including splanchnic, lower extremity arteries, and aorta in essential thrombocythemia. A 70-year-old woman was admitted to the emergency room with abdominal pain and fever for a day. The patient underwent three operations due to recurrent arterial thrombosis of superior mesenteric, splenic, aorta, and lower extremities. She had recurrent diarrhea and acute kidney injury because of short bowel syndrome after extensive bowel resection. In conclusion, essential thrombocythemia patients aged >60 years and who have risk factors such as history of major ischemic events or severe leukocytosis must be careful of thrombosis of the medium- and large-sized arteries, including splanchnic and lower extremity arteries.

Endovenous Intervention of May-Thurner Syndrome with Thrombus beyond Iliac Vein Stenosis

Purpose

With the increase in the incidence of venous thrombosis, interest in May-Thurner syndrome (MTS) accompanying iliac vein compression has increased. Some patients with MTS have inferior vena cava thrombosis or thrombosis beyond iliac vein stenosis (TBIVS). This study aimed to identify the characteristics of MTS with TBIVS including pulmonary embolism (PE) and post-thrombotic syndrome (PTS) compared to those of MTS without TBIVS.

Materials and Methods

Thirty-five patients with deep vein thrombosis associated with MTS were treated between March 2012 and February 2016. Demographic data, medical history, computed tomography findings (iliac vein size of stenosis and stenotic ratio compared with the other side), and clinical outcomes (preoperative PE and PTS) were retrospectively collected and reviewed by dividing into groups with or without TBIVS.

Results

Eight of the 35 patients with MTS had TBIVS. The group with TBIVS had a statistically significantly greater iliac vein size (P<0.001) and ratio (P=0.001). PE was more prevalent in the group with TBIVS (63% vs. 15%, P=0.007). However, no statistically significant intergroup difference in PTS prevalence was found.

Conclusion

The presence of mild iliac vein stenosis in MTS can be used to predict TBIVS and the requirement for more attention to PE.

Effect of Cinacalcet in Kidney Transplant Patients With Hyperparathyroidism

OBJECTIVE

In dialysis patients, cinacalcet could be an effective alternative to parathyroidectomy for treating hyperparathyroidism. In the present study, we aimed to determine the characteristics of subjects with persistent hyperparathyroidism who require parathyroidectomy despite the use of cinacalcet.

METHODS

Nine kidney transplant patients (7 men, 2 women; mean age 53.2 [SD, 8.9] years) who had tertiary hyperparathyroidism were reviewed in a single center. Pre- and postcinacalcet levels of calcium, phosphorous, intact parathyroid hormone (iPTH), and renal function were analyzed to evaluate the effect of cinacalcet treatment in these patients. The baseline parameters before cinacalcet treatment were compared in patients who did and did not undergo parathyroidectomy.

RESULTS

Cinacalcet reduced serum calcium levels in all patients (11.48 [SD, 0.73] mg/dL to 10.20 [0.70] mg/dL; P = .008). Serum phosphorous levels significantly increased from 2.28 (SD, 0.77) mg/dL to 3.02 (SD, 0.65) mg/dL (P = .03). The iPTH levels in 7 patients decreased, while the mean level remained unchanged in total subjects. The iPTH levels increased even with cinacalcet treatment in 2 patients. In 3 patients, serum calcium levels abruptly increased after cinacalcet withdrawal. Five patients who showed persistent hypercalcemia due to hyperparathyroidism underwent parathyroidectomy. These 5 patients had significantly different characteristics compared with 4 patients who did not undergo parathyroidectomy: hypercalcemia (11.92 [SD, 0.68] mg/dL vs 10.93 [SD, 0.26] mg/dL; P = .02), hypophosphatemia (1.74 [SD, 0.36] mg/dL vs 2.95 [SD, 0.58] mg/dL; P = .03), and hyperparathyroidism (252.2 [SD, 131.4] pg/dL vs 101.5 [SD, 18.4] pg/dL; P = .02).

CONCLUSION

Cinacalcet reduced hypercalcemia due to hyperparathyroidism in the transplant patients. However, patients who had pre-existing higher iPTH, hypercalcemia, and hypophosphatemia needed parathyroidectomy. Therefore, cinacalcet could be considered an alternative to parathyroidectomy in selected patients.

Clinical Manifestations of Superior Mesenteric Venous Thrombosis in the Era of Computed Tomography

Purpose

Thrombosis of the portal vein, known as pylephlebitis, is a rare and fatal complication caused by intraperitoneal infections. The disease progression of superior mesenteric venous thrombosis (SMVT) is not severe. This study aimed to determine the clinical features, etiology, and prognosis of SMVT.

Materials and Methods

We retrospectively reviewed the medical records of 41 patients with SMVT from March 2000 to February 2017. We obtained a list of 305 patients through the International Classification of Disease-9 code system and selected 41 patients with SMVT with computed tomography. Data from the medical records included patient demographics, comorbidities, review of system, laboratory results, clinical courses, and treatment modalities.

Results

The causes of SMVT were found to be intraperitoneal inflammation in 27 patients (65.9%), malignancy in 7 patients (17.1%), and unknown in 7 patients (17.1%). Among the patients with intraperitoneal inflammation, 14 presented with appendicitis (51.9%), 7 with diverticulitis (25.9%), and 2 with ileus (7.4%). When comparing patients with and without small bowel resection, the differences in symptom duration, bowel enhancement and blood culture were significant (P=0.010, P=0.039, and P=0.028, respectively).

Conclusion

SMVT, caused by intraperitoneal inflammation, unlike portal vein thrombosis including pylephlebitis, shows mild prognosis. In addition, rapid symptom progression and positive blood culture can be the prognostic factors related to extensive bowel resection. Use of appropriate antibiotics and understanding of disease progression can help improve the outcomes of patients with SMVT.

Trends in endovascular aneurysm repair research: bibliometric analysis from 1994 to 2017

Purpose

Since endovascular aneurysm repair (EVAR) was first introduced in 1991, it has undergone rapid technical and quantitative developments. We analyzed the characteristics and trends of EVAR research through bibliometric analysis.

Methods

Comprehensive online searches focused on EVAR were performed from January 1994 to August 2017. The following information was collected: title, year of publication, countries' contribution, authorship, subspecialty, institution, subject category, and top 10 cited articles.

Results

A significant increase was demonstrated globally in the number of annual publications on EVAR. The highest number of publications was from the United States (n = 849, 35.08%), followed by England (n = 343, 14.17%), and the institutions with highest number of publications were Stanford University (n = 61, 2.52%) and Skane University Hospital Malmo (n = 45, 1.86%). The Journal of Vascular Surgery published approximately one quarter of the total publications. Vascular surgeons produced the most publications (n = 1871, 78.14%), followed by radiologists (n = 377, 15.58%) and cardiologists (n = 73, 3.02%). The most studied topics on EVAR were complications and procedures. The number of publications on complex EVAR and EVAR in juxtarenal aneurysm has increased more from 2013 to 2017 (5.1%, 9.5%) compared with from 1998 to 2002 (2.1%, 1.8%).

Conclusion

Our bibliometric analysis showed the characteristics and trends of publications on EVAR over a period of 25 years. The results of the bibliometric analysis revealed the quantitative improvements of publications and the qualitative improvements in challenging EVAR.

An OLTAM system for analysis of brown/beige fat thermogenic activity

BACKGROUND/OBJECTIVES

Thermogenic fat is present in humans and emerging evidence indicates that increasing the content and activity of these adipocytes may lead to weight loss and improved metabolic health. Multiple reporter systems have been developed to assay thermogenic fat activity based on the transcriptional and translational activation of Ucp1, the key molecule that mediates nonshivering thermogenesis. Our study aims to develop a much-needed tool to monitor thermogenic fat activity through a mechanism independent of Ucp1 regulation, therefore effectively assaying not only canonical β-adrenergic activation but also various non-UCP1-mediated thermogenic pathways that have been increasingly appreciated.

METHODS

We detected increased luciferase activity upon thermogenic activation in interscapular brown and inguinal subcutaneous fat in ODD-Luc mice, a hypoxia reporter mouse model. We then developed an OLTAM (ODD-Luc based Thermogenic Activity Measurement) system to assay thermogenic fat cell activity.

RESULTS

In both primary murine and human adipocytes and an immortalized adipose cell line that were transduced with the OLTAM system, luciferase activity can be readily measured and visualized by bioluminescence imaging in response to a variety of stimuli, including UCP1-independent thermogenic signaling. This system can offer a convenient method to assay thermogenic activity for both basic and translational research.

CONCLUSIONS

The OLTAM system offers a convenient way to measure of the activation of thermogenic fat and presents opportunities to discover novel signaling pathways and unknown compounds targeting metabolically active adipocytes to counteract human obesity.

Kidney Donor Risk Index as the Predictor for the Short-term Clinical Outcomes After Kidney Transplant From Deceased Donor With Acute Kidney Injury

BACKGROUND

The Kidney Donor Risk Index (KDRI) scoring system for deceased donors has been widely introduced for postoperative evaluation of graft function. We analyzed the usefulness of the KDRI in deceased donors with acute kidney injury (AKI).

METHODS

Forty-nine recipients from deceased donors with AKI between January 2009 and December 2014 were reviewed retrospectively. Data collected from donor medical records included age, height, weight, hypertension or diabetes history, cause of death, serum creatinine (sCr), and donation after cardiac death. Graft function data including sCr, estimated glomerular filtration rate (eGFR), and acute rejection episodes were monitored for 1 year. Correlations between KDRI score and factors indicating graft function were analyzed. A cutoff value for KDRI score was calculated using a receiver operating characteristic (ROC) curve for significant graft function.

RESULTS

The mean ages of donors and recipients were 46.81 ± 13.13 and 47.69 ± 11.43, respectively. The mean KDRI score was 1.24 ± 0.40. Univariable analysis of KDRI score and factors indicating graft function indicated that sCr at 6 to 12 months, eGFR at 1 year, and slow graft function (SGF) had statistical significance. The ROC curve of KDRI score for SGF showed an optimal cutoff value of 1.20, with sensitivity of 69.2% and specificity of 69.4% (area under the curve = 0.75) in deceased donors with AKI.

CONCLUSIONS

KDRI score in deceased donors with AKI was correlated with postoperative graft values including eGFR and SGF. KDRI could be used as a predictor for the short-term clinical outcome after kidney transplant from deceased donor with AKI.

Immunoglobulin G4-Related Inflammatory Abdominal Aortic Aneurysm Associated With Myasthenia Gravis, With Contained Rupture

Immunoglobulin (Ig) G4-related disease is reportedly among the various causes of inflammatory abdominal aortic aneurysm (IAAA). Many IgG4-related diseases are closely related to allergic constitution and autoimmune disease. We report a case of a 72-year-old man with IgG4-related IAAA associated with myasthenia gravis, with contained rupture.

Evaluation of postoperative lymphocele according to amounts and symptoms by using 3-dimensional CT volumetry in kidney transplant recipients

Purpose

To analyze the risk factors for postoperative lymphocele, for predicting and preventing complications.

Methods

We evaluated 92 kidney transplant recipients with multidetector CT (MDCT) at 1-month posttransplantation. From admission and 1-month postoperative records, data including diabetes, dialysis type, immunosuppressant use, steroid pulse therapy, and transplantation side were collected. Lymphocele volume was measured with 3-dimensional reconstructed, nonenhanced MDCT at one month postoperatively. The correlations between risk factors and lymphocele volume and between risk factors and symptomatic lymphocele (SyL) were analyzed. The cutoff was calculated by using the receiver operating characteristic (ROC) curve for SyL volume.

Results

Among 92 recipients, the mean volume was 44.53 ± 176.43 cm³ and 12 had SyL. Univariable analysis between risk factors and lymphocele volume indicated that donor age, retransplantation, and inferiorly located lymphocele were statistically significant. The ROC curve for SyL showed that 33.20 cm³ was the cutoff, with 83.3% sensitivity and 93.7% specificity. On univariable analysis between risk factors and SyL, steroid pulse, inferiorly located lymphocele, and >33.20 cm³ were statistically significant. Multivariable analysis indicated that steroid pulse, >33.20 cm³, and serum creatinine level at one month were significant factors.

Conclusion

Risk factors including donor age, retransplantation, steroid pulse therapy, and inferiorly located lymphocele are important predictors of large lymphoceles or SyL. In high-risk recipients, careful monitoring of renal function and early image surveillance such as CT or ultrasound are recommended. If the asymptomatic lymphocele is >33.20 cm³ or located inferiorly, early interventions can be considered while carefully observing the changes in symptoms.