A case of Trousseau's syndrome due to intrahepatic cholangiocarcinoma with an extremely high level of CA19-9

BACKGROUND

Trousseau's syndrome is a cancer-associated thrombosis. Trousseau's syndrome with cholangiocarcinoma is a rare condition with poor prognosis.

CASE PRESENTATION

A 59-year-old female was admitted to our hospital with abdominal pain, headache, and nausea. Abdominal enhanced computed tomography revealed liver tumor, splenic infarction, and bilateral renal infarction. Multiple acute cerebral infarctions were also detected by magnetic resonance imaging. Her preoperative serum levels of carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA) were > 120,000 U/mL and 589.6 ng/mL, respectively, which were extremely high. Histopathology after right hepatectomy revealed moderately differentiated adenocarcinoma consistent with intrahepatic cholangiocarcinoma. Her serum levels of CA19-9 were trending down to 9029.2 and 2659.8 U/mL at 1 and 3 weeks after surgery, respectively. However, at 7 weeks after surgery, her CA19-9 levels increased in the presence of positive imaging findings in the remnant liver, hilar lymph nodes, and peritoneal cavity. The initiation of combination chemotherapy including gemcitabine and cisplatin had a significant effect. The patient was doing well at 6 months after the surgery.

CONCLUSION

This rare case of Trousseau's syndrome due to cholangiocarcinoma suggests that extremely high CA19-9 levels might be a pathogenic factor of this syndrome.

Laparoscopic surgery for two patients with strangulated transomental hernias

Background

Transomental hernias are a rare type of internal hernia. We report two cases of successful cases of laparoscopic repair. One required laparotomy due to concern for intestinal viability.

Case presentation

The first patient was a 67-year-old man who presented with abdominal pain and vomiting. He had no history of laparotomy or abdominal injury. Computed tomography suggested small bowel obstruction and possible intestinal strangulation. Emergent laparoscopy found approximately 200 cm of small bowel was strangulated around the greater omentum. The strangulation was released laparoscopically, but because of the color of the strangulated bowel, laparotomy was performed to evaluate viability. The involved portion of intestine was not resected. The patient experienced transient postoperative paralytic ileus and was discharged on postoperative day 14. The second patient was a 56-year-old man who presented with abdominal pain. Abdominal computed tomography revealed dilatation of the small intestine and a closed loop suggesting ileus due to intestinal strangulation. An emergency laparoscopy found a transomental hernia, and the strangulation was released laparoscopically. Recovery was uneventful, and the patient was discharged on postoperative day 6.

Conclusion

Transomental hernia can be successfully treated laparoscopically. In cases where bowel viability is a concern, laparotomy should not be hesitated.

Single incision laparoscopic surgery (SILS) for Meckel's diverticulum

A 65-year-old male patient presented with a chief complaint of abdominal pain. Abdominal computed tomography (CT) showed slight intestinal dilation and obstruction of the upper right quadrant of the small intestine, while ectopic gastric mucosal scintigraphy revealed abnormal accumulation in agreement with the CT-identified structure. The cause of bowel obstruction was diagnosed as Meckel’s diverticulum; the patient was referred for surgery. A small laparotomy was performed with a 35-mm skin incision to the center of the navel. Once a lap disk was attached, a laparoscope was inserted to visualize the abdominal cavity. The small intestine that includes the structure was pulled out from the umbilicus to the outside of the peritoneal cavity and partially resected. On the pathological tissue findings, the patient was diagnosed with Meckel’s diverticulum. We report our experience with single-lap laparoscopic surgery for a case of intestinal obstruction caused by Meckel’s diverticulum and review pertinent literature.

Hypogenesis of right hepatic lobe in a laparoscopic cholecystectomy for acute gallstone cholecystitis: A case report

Hypogenesis or agenesis of right hepatic lobe is a rare abnormality and is generally associated with gallbladder and biliary tract abnormalities. Cases of biliary injury following cholecystectomy have been reported in patients with agenesis of right hepatic lobe because the anatomical anomalies complicate the surgical approach. We report a case of laparoscopic cholecystectomy in a patient with hypogenesis of right hepatic lobe. A 92-year-old male patient was admitted to our hospital with fever and right lower abdominal pain with suspected acute appendicitis. Abdominal computed tomography revealed gallstones with acute cholecystitis and hypogenesis of right hepatic lobe. He underwent laparoscopic cholecystectomy with the left semilateral decubitus position. The patient's postoperative course was uneventful. In conclusions, some patients with liver lobe hypoplasia do not present with the typical symptoms of acute cholecystitis due to dislocation of the gallbladder. The left semilateral decubitus position with modified placement of port sites is useful for laparoscopic cholecystectomy in patients with hypogenesis of right hepatic lobe.

Early and Mid-Term Outcomes after Vascular Reconstruction for Patients with Lower-Extremity Soft-Tissue Malignant Tumors

Objective: To evaluate limb-salvage surgery including vascular resection for lower-extremity soft-tissue sarcomas and carcinomas for adult patients.

Materials and Methods: Eight consecutive patients (median age, 59 years) who underwent vascular replacement during surgery for malignant tumors in the lower limbs between November 2006 and March 2018 were evaluated. Patient data were retrospectively obtained in a computerized database. Arterial and venous reconstructions were performed for seven patients, with one additional patient receiving venous reconstruction only. Autologous-vein (n=6) and synthetic bypasses were used for arterial repairs, whereas only autologous veins were implanted for venous repairs.

Results: Morbidity was 62.5%, and in-hospital mortality was 12.5%. At a median follow-up of 24 months, the primary patency rates of arterial and venous reconstructions were 85.7% and 62.5%, respectively. Limb salvage was achieved in all cases.

Conclusion: Early and mid-term bypass patency rates, the high percentage of limb salvage, and the oncologic outcome underline the efficacy of en bloc resection of soft-tissue tumors involving major vessels of the lower limbs. The anticipated need for vascular resection and reconstruction should not be a contraindication to sarcoma and carcinoma resections. However, efforts to achieve better control over systemic spread are required for long-term survival.

Electrochemistry of DNA duplex containing an anthraquinonylmethyl group at the 2'-sugar position

Cyclic voltammetry of oligonucleotide containing an anthraquinonylmethyl group at the 2'-sugar position was carried out for exploiting an electrochemical probe of DNA.

Chlorella vulgaris culture supernatant (CVS) reduces psychological stress-induced apoptosis in thymocytes of mice

A glycoprotein prepared from Chlorella vulgaris culture supernatant (CVS) is a biological response modifier (BRM) which exhibits protective activities against tumor metastasis and 5-fluorouracil-induced immunosuppression. We here show that oral administration of CVS prevented significantly the apoptosis of thymocytes in mice undergoing psychological stress in a communication box. Mice were exposed to the emotional stress for 14 days by witnessing other mice being exposed to foot-shock. The numbers in thymocytes, especially CD4(+)CD8(+) population, were decreased significantly and apoptotic cells, as assessed by Annexin V expression, were reciprocally increased after the exposure to the psychological stress. C. vulgaris culture supernatant (CVS) administration significantly suppressed the increase in serum corticosterone level in the psychologically stressed mice. These results suggest that CVS prevents psychological stress and maintain homeostasis in the face of external environmental changes.

Oral administration of hot water extracts of Chlorella vulgaris reduces IgE production against milk casein in mice

Hot water extract of Chlorella vulgaris (CVE) is a biological response modifier (BRM) which enhances resistance to Listeria monocytogenes through augmentation of helper T cell type 1 (Thl) responses producing gamma-interferon (gammaIFN). We show here that oral administration of CVE in mice suppressed the production of immunoglobulin (Ig)E against casein antigen accompanied by increased gammaIFN and IL-12 mRNA expression. Oral administration of CVE enhanced Thl response to casein in the spleen of casein immunized mice. CVE may be useful for prevention of allergic diseases with a predominant Th2 response.

Enhanced resistance against Escherichia coli infection by subcutaneous administration of the hot-water extract of Chlorella vulgaris in cyclophosphamide-treated mice

The effects of Chlorella vulgaris extract (CVE-A) on the recovery of leukocyte number and the augmentation of resistance to bacterial infection were examined in CDF1 mice made neutropenic by cyclophosphamide (CY). They were treated intraperitoneally with CY (150 mg/kg) on day 0, and were given CVE-A (50 mg/kg) subcutaneously (s.c.) every other day from day 1 to day 13 after CY treatment. CVE-A accelerated the recovery of polymorphonuclear leukocytes (PMN) in the peripheral blood in CY-treated mice. The number of granulocyte/monocyte-progenitor cells (CFU-GM) in the spleen increased rapidly and highly after the administration of CVE-A in CY-treated mice, in contrast to the absence of change due to CVE-A in the number of bone marrow cells in CY-treated mice. Administration of CVE-A in CY-treated mice enhanced the accumulation of PMN in the inflammatory site and the activity of the accumulated leukocyte cells in luminol-dependent chemiluminescence. The mice became highly susceptible to an intraperitoneal infection with E. coli on day 4 after CY treatment, whereas the mice given CVE-A showed an enhanced resistance against E. coli infection, irrespective of the timing of challenge. The bacterial number in CY-treated mice increased explosively after inoculation, resulting in death within 24 h. A progressive elimination of bacteria was observed from 6 h in the peritoneal cavity, spleen and liver of CY-treated mice given CVE-A s.c. These results indicate that CVE-A can be used as a potent stimulant of nonspecific resistance to infection in neutropenic mice.

Serum-free culture of insulin-secreting clonal cells from a hamster insulinoma

We experimented with a wide range of serum-free media to find the best one for culturing insulinoma cells from the Syrian golden hamster, cell line In-R1-I10. Optimum cell growth came with a mixture of equal proportions of Dulbecco's modified Eagle's medium and Ham's F-12, supplemented with 10(-6) M insulin, 10 micrograms/ml transferrin, and 10(-9) M triiodothyronine (what we labeled DF-ITT medium). In addition to testing different varieties of basal media, we also experimented with different concentrations of known stimulants of cell proliferation, including transferrin, ferrous sulfate, insulin, epidermal growth factor, triiodothyronine, hydrocortisone, monoethanolamine, prolactin, proteose peptone, and selenium. Cells cultured in DF-ITT medium grew as well as those in serum-containing medium for 94 consecutive generations. Their insulin secreting capacity was maintained. The substitution of epidermal growth factor (10 ng/ml) for the insulin did not reduce either the growth rate or the insulin secreting capacity of the culture cells.