Publications by authors named "Hikotaro Katsura"

8 Publications

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Diffuse large B-cell lymphoma in the liver accompanied by primary biliary cholangitis: A rare and difficult-to-diagnose tumor with portal venous thrombosis.

Int J Surg Case Rep 2021 May 30;82:105936. Epub 2021 Apr 30.

Department of Surgery, Shiga General Hospital, Moriyama, 5-4-30 Moriyama, Moriyama, Shiga 524-8524, Japan. Electronic address:

Introduction And Importance: The most common liver malignancies are hepatocellular carcinoma, intrahepatic cholangiocarcinoma, and metastatic tumors. Hepatocellular carcinoma and intrahepatic cholangiocarcinoma may invade the portal vein (PV). An association between diffuse large B-cell lymphoma (DLBCL) and primary biliary cholangitis (PBC) remains unclear. We herein report a thought-provoking case of a difficult-to-diagnose liver tumor with PV thrombosis in a PBC patient.

Presentation Of Case: A 66-year-old woman had PBC, systemic sclerosis, diabetes, and osteoporosis. A solitary liver tumor accompanied by macrovascular thrombosis in the PV was detected incidentally. Based on dynamic imaging findings, we considered the tumor to be intrahepatic cholangiocarcinoma, and right lobectomy with lymphadenectomy was performed. Unexpectedly, pathological assessment made a definitive diagnosis of DLBCL that did not invade the vessels and bile duct. In fluorine-18-fluorodeoxyglucose positron emission tomography, abnormal accumulations were clearly observed in the breast tissue and peritracheal, parasternal, mediastinal, and pericardial lymph nodes. The patient achieved complete remission after systemic chemotherapy, and there has been no recurrence 3 years after surgery.

Clinical Discussion: Primary lymphoma in the liver is rare, and we did not consider our patient's tumor as primary liver lymphoma. Our case actually showed no tumor thrombosis in the PV. Although autoimmune disorders may increase the risk of non-Hodgkin's lymphoma, an association between DLBCL and PBC is still unclear, and we must remember that DLBCL may develop rarely in a PBC patient.

Conclusion: Our case report provides a timely reminder for clinicians and surgeons in the fields of hepatology and hematology.
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http://dx.doi.org/10.1016/j.ijscr.2021.105936DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8114119PMC
May 2021

Fatal arterial hemorrhage after pancreaticoduodenectomy: How do we simultaneously accomplish complete hemostasis and hepatic arterial flow?

World J Hepatol 2021 Apr;13(4):483-503

Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan.

Background: Although arterial hemorrhage after pancreaticoduodenectomy (PD) is not frequent, it is fatal. Arterial hemorrhage is caused by pseudoaneurysm rupture, and the gastroduodenal artery stump and hepatic artery (HA) are frequent culprit vessels. Diagnostic procedures and imaging modalities are associated with certain difficulties. Simultaneous accomplishment of complete hemostasis and HA flow preservation is difficult after PD. Although complete hemostasis may be obtained by endovascular treatment (EVT) or surgery, liver infarction caused by hepatic ischemia and/or liver abscesses caused by biliary ischemia may occur. We herein discuss therapeutic options for fatal arterial hemorrhage after PD.

Aim: To present our data here along with a discussion of therapeutic strategies for fatal arterial hemorrhage after PD.

Methods: We retrospectively investigated 16 patients who developed arterial hemorrhage after PD. The patients' clinical characteristics, diagnostic procedures, actual treatments [transcatheter arterial embolization (TAE), stent-graft placement, or surgery], clinical courses, and outcomes were evaluated.

Results: The frequency of arterial hemorrhage after PD was 5.5%. Pancreatic leakage was observed in 12 patients. The onset of hemorrhage occurred at a median of 18 d after PD. Sentinel bleeding was observed in five patients. The initial EVT procedures were stent-graft placement in seven patients, TAE in six patients, and combined therapy in two patients. The rate of technical success of the initial EVT was 75.0%, and additional EVTs were performed in four patients. Surgical approaches including arterioportal shunting were performed in eight patients. Liver infarction was observed in two patients after TAE. Two patients showed a poor outcome even after successful EVT. These four patients with poor clinical courses and outcomes had a poor clinical condition before EVT. Fourteen patients were successfully treated.

Conclusion: Transcatheter placement of a covered stent may be useful for simultaneous accomplishment of complete hemostasis and HA flow preservation.
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http://dx.doi.org/10.4254/wjh.v13.i4.483DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8080554PMC
April 2021

Aggressive Resection of Malignant Paraaortic and Pelvic Tumors Accompanied by Arterial Reconstruction with Synthetic Arterial Graft.

Am J Case Rep 2021 May 1;22:e931569. Epub 2021 May 1.

Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan.

BACKGROUND Advanced malignancies in the lower abdomen easily invade the retroperitoneal and pelvic space and often metastasize to the paraaortic and pelvic lymph nodes (LNs), resulting in paraaortic and/or pelvic tumor (PPT). CASE REPORT A total of 7 cases of aggressive malignant PPT resection and orthotopic replacement of the abdominal aorta and/or iliac arteries with synthetic arterial graft (SAG) were experienced during 16 years. We present our experience with aggressive resection of malignant PPTs accompanied by arterial reconstruction with SAG in detail. The primary diseases included 2 cases endometrial cancer and 2 cases of rectal cancer, and 1 case each of ovarian carcinosarcoma, vaginal malignant melanoma, and sigmoid cancer. Surgical procedures are described in detail. Briefly, the abdominal aorta and iliac arteries were anastomosed to the SAG by continuous running suture using unabsorbent polypropylene. Five Y-shaped and 2 I-shaped SAGs were used. This en bloc resection actually provided safe surgical margins, and tumor exposures were not pathologically observed in the cut surfaces. Graphical and surgical curability were obtained in all cases in which aggressive malignant PPT resections were performed. The short-term postoperative course of our patients was uneventful. From a vascular perspective, the SAGs remained patent over the long term after surgery, and long-term oncologic outcomes were satisfactory. CONCLUSIONS To our knowledge, this case series is the first report of aggressive malignant PPT resection accompanied by arterial reconstruction with SAG. This procedure is safe and feasible, shows curative potential, and may play a role in multidisciplinary management of malignant PPTs.
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http://dx.doi.org/10.12659/AJCR.931569DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8097745PMC
May 2021

Mucinous Cystic Adenoma of the Liver: A Thought-Provoking Case of an Uncommon Hepatic Neoplasm.

Am J Case Rep 2021 Apr 3;22:e931368. Epub 2021 Apr 3.

Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan.

BACKGROUND Mucinous cystic neoplasm (MCN) of the liver is a rare hepatic neoplasm: a cystic, mucus-producing tumor. Histopathologic examination reveals ovarian-like stroma. The origin of MCN of the liver is still unknown, although ectopic ovarian-like stroma in the liver has been suggested as a possibility. We document a thought-provoking case of MCN of the liver, and intratumoral fatty tissue may support the opinion that ectopic ovarian-like stroma in the liver is a possible origin for both MCN and ovarian teratoma. CASE REPORT An expansive 10.5-cm cystic tumor was incidentally detected in a 71-year-old woman. Imaging studies revealed that the tumor was multiloculated, with cyst contents comprising mucus, muddy-looking fluid (inspissated bile), and hematoma. Imaging studies revealed fatty tissue and calcifications in the cyst walls. The diagnosis of MCN of the liver was made, although MCNs have never been reported to include fatty tissue. Extended left lobectomy was performed, and the tumor was curatively removed without any rupture. A multilocular cyst, mucus, calcifications, and fatty tissue were clearly observed on gross inspection. Histopathological examination revealed ovarian-like stroma. Evidence of malignancy was not detected. Her postoperative course was uneventful. To the best of our knowledge, our patient is the first case of MCN of the liver with intratumoral fatty tissue. This case may support the hypothesis that MCN originates from ectopic ovarian-like stroma in the liver. CONCLUSIONS We documented a thought-provoking case of MCN of the liver in detail, and this MCN accompanied with fatty tissue might originate from ectopic ovarian-like stroma.
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http://dx.doi.org/10.12659/AJCR.931368DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8029594PMC
April 2021

Adrenocorticotropic hormone-dependent hypercortisolism caused by pancreatic neuroendocrine carcinoma: A thought-provoking but remorseful case of delayed diagnosis.

Int J Surg Case Rep 2021 Apr 5;81:105729. Epub 2021 Mar 5.

Department of Surgery, Shiga General Hospital, Moriyama, 5-4-30 Moriyama, Moriyama, Shiga, 524-8524, Japan. Electronic address:

Introduction And Importance: Definitive diagnosis of functioning neuroendocrine neoplasms (NENs) in the pancreas is challenging. Adrenocorticotropic hormone (ACTH) regulates adrenal cortisol production. Ectopic ACTH secretion by functioning NENs may cause hypercortisolism.

Presentation Of Case: A 62-year-old woman who was receiving medications for hypertension and hyperlipidemia was referred to our hospital because of abnormal blood tests. Diabetes mellitus was initially diagnosed. Dynamic computed tomography and endoscopic ultrasound revealed a 35-mm diameter hypovascular tumor in the distal pancreas and multiple liver metastases. Endoscopic ultrasound-guided fine-needle aspiration resulted in a diagnosis of neuroendocrine carcinoma. The patient developed pancreatic leakage progressing to peritonitis, abscess formation, pleural effusion, and ascites after the fine-needle aspiration biopsy. Her clinical condition deteriorated to a septic state, necessitating emergency surgery comprising distal pancreatectomy, intraperitoneal lavage, and drainage. Wound healing was protracted and accompanied by ongoing high white blood cell counts and neutrophilia. She also developed a gastric ulcer postoperatively. Systematic endocrine investigations were performed because hypercortisolism caused by a functioning NEN was suspected. Eventually, a definitive diagnosis of an ACTH-producing NEN in the pancreas was made. Systemic chemotherapy was proposed; however, the patient and her family opted for palliative treatment only. She died 42 days after the initial diagnosis.

Clinical Discussion: We here present a patient with ACTH-dependent hypercortisolism attributable to a pancreatic NEN who died of progressive cancer after a delay in definitive diagnosis.

Conclusion: Detailed investigation, including systematic endocrine examination and functional imaging studies, are important for precise diagnosis of, and appropriate treatment for, NENs.
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http://dx.doi.org/10.1016/j.ijscr.2021.105729DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957145PMC
April 2021

Ectopic endometriosis, menstruation, and acute appendicitis: A thought-provoking case.

Int J Surg Case Rep 2021 Mar 1;80:105605. Epub 2021 Feb 1.

Department of Surgery, Shiga General Hospital, Moriyama, 5-4-30 Moriyama, Moriyama, Shiga 524-8524, Japan. Electronic address:

Introduction And Importance: Ectopic endometrium in the appendix is rare. The relationships between ectopic endometrium in the alimentary tract and digestive symptoms and between digestive symptoms due to ectopic endometriosis and periodic menstruation are controversial. We herein describe the successful treatment of acute appendicitis that we suspect was caused by ectopic endometriosis and periodic menstruation.

Presentation Of Case: A 38.9-year-old multipara with uterine didelphys developed lower abdominal pain during menstruation, and she was clinically diagnosed with acute appendicitis. She received conservative management with cephem antibiotics, and her pain disappeared uneventfully. However, the lower abdominal pain during menstruation later recurred, and she again received conservative treatment. Laparoscopic appendectomy was subsequently performed because for 4 months, her appendicitis-induced digestive symptoms had recurred in association with periodic menstruation. Ectopic endometrial gland proliferations were histopathologically observed in the proper muscular layer of the appendiceal tip. She developed no further episodes of digestive symptoms postoperatively.

Clinical Discussion: Ectopic endometriosis of the alimentary tract may be accompanied by digestive symptoms; moreover, these symptoms may be related to periodic menstruation. However, the sensitivity of ectopic endometrium to hormones shows considerable variation among patients. We speculate that the acute appendicitis might have been triggered by ectopic endometriosis in our case because the patient developed repeated digestive symptoms in association with periodic menstruation. Ectopic endometrium may be incidentally observed in histopathological assessments of resected specimens. The therapeutic strategy should be carefully decided on a case-by-case basis.

Conclusion: We hope this thought-provoking case provides a timely reminder for gastrointestinal clinicians and general surgeons.
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http://dx.doi.org/10.1016/j.ijscr.2021.01.099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7893425PMC
March 2021

Acute intestinal infarction caused by initially unexplained splanchnic venous thromboses in a patient with protein C deficiency: A thought-provoking emergency case.

Int J Surg Case Rep 2021 Feb 22;79:390-393. Epub 2021 Jan 22.

Department of Surgery, Shiga General Hospital, 5-4-30 Moriyama, Moriyama, Shiga, 524-8524, Japan. Electronic address:

Introduction And Importance: Splanchnic venous thrombosis (SVT) originating in the superior mesenteric vein (SMV) is rare and may cause acute intestinal infarction (AII). Protein C deficiency (PCD) results in thrombophilia.

Presentation Of Case: Acute unexplained SVT originating in the SMV and portal vein was detected in 68-year-old man. Pan-peritonitis and AII were diagnosed and emergency surgery performed. Part of the small intestine was necrotic and partial resection without anastomotic reconstruction was performed. Heparin was administered intravenously continuously from postoperative day (POD) 1. Hereditary, heterozygous, type 1 PCD was diagnosed postoperatively. The anastomosis was reconstructed on POD 16. Warfarin was substituted for heparin on POD 22. No recurrent thrombosis occurred during 2 years of follow-up.

Clinical Discussion: Patients with the rare condition of SVT require prompt diagnosis and treatment and may have underlying disease. PCD can cause SVT even in intact veins and anticoagulation therapy should be administered immediately postoperatively. Misdiagnosis and/or delayed treatment of SVT can result in AII, a life-threatening condition with a high mortality rate. Insufficient clinician awareness can result in serious mismanagement of patients with PCD and SVT; emergency patients with AII caused by unexplained SVT should therefore be further investigated for prothrombotic states and assessment of coagulation-fibrinolysis profiles to clarify the underlying mechanism.

Conclusion: We here present a thought-provoking emergency case of AII associated with acute SVT caused by underlying PCD that was successfully treated by two-stage surgery and anticoagulation therapy. This case provides a timely reminder for emergency clinicians and gastrointestinal surgeons.
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http://dx.doi.org/10.1016/j.ijscr.2021.01.071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7848722PMC
February 2021

Biphasic clinical course of a ruptured right gastric artery aneurysm caused by segmental arterial mediolysis: a case report.

BMC Surg 2020 Aug 27;20(1):191. Epub 2020 Aug 27.

Department of gastrointestinal surgery, Shinko Hospital, 1-4-47 Wakinohama-cho, Chuo-ku, Kobe, 651-0072, Japan.

Background: Gastric artery aneurysms are rarely caused by segmental arterial mediolysis (SAM), a condition that often involves multiple vessels. The clinical course of SAM after vessel rupture may vary depending on the involved vessels. For example, the "double-rupture phenomenon" observed following the rupture of the splenic artery aneurysm manifests as a biphasic and relatively slow clinical course. Even in cases of rupture of gastric artery aneurysm, the double-rupture phenomenon has only been reported in two cases so far. However, the rupture was not caused by SAM in either case. Herein, we present the apparent first case of a right gastric artery (RGA) aneurysm rupture caused by SAM that presented with a biphasic clinical course, possibly due to the double-rupture phenomenon.

Case Presentation: A 54-year-old woman was transferred to the emergency department with severe abdominal pain and a cold sweat for a duration of 3 h. She had developed mild abdominal pain and nausea 3 days earlier. Her vital signs were stable. Physical examination revealed tenderness in the epigastric area. Abdominal contrast-enhanced computed tomography revealed an RGA aneurysm with contrast media extravasation. A diagnosis of hemoperitoneum following a ruptured RGA aneurysm was made, and the patient underwent angiography. However, this modality did not reveal any extravasation from the RGA due to an interruption in the peripheral branch of the artery. Nevertheless, to prevent major bleeding, we performed coil embolization at the point of interruption in the RGA, which we suspected to be a ruptured aneurysm. A distal gastrectomy with Roux-en-Y reconstruction for aneurysm resection was performed the following day. There were no postoperative complications, and the patient was discharged 17 days after surgery. Histologically, the RGA demonstrated multiple vacuoles in the medial muscle layer, which were characteristic of SAM.

Conclusions: An RGA aneurysm rupture should be considered a differential diagnosis in patients presenting with hemoperitoneum with a slow or biphasic clinical course.
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http://dx.doi.org/10.1186/s12893-020-00849-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7450588PMC
August 2020