Akihiro Cho

High preoperative neutrophil-lymphocyte ratio predicts poor survival in patients with gastric cancer

BackgroundThe neutrophil-lymphocyte ratio (NLR) reflects inflammatory status. An elevated NLR has been reported to be a prognostic indicator in some malignant tumors. The aim of this study was to evaluate the clinical significance of the preoperative NLR in patients with primary gastric cancer.MethodsA total of 709 men and 319 women, with a mean age of 64.4 years, who underwent gastrectomy were included. The numbers of patients in each pathological stage were as follows: stage I, 584; stage II, 132; stage III, 153; and stage IV, 159. The mean NLR was 2.62 ± 1.68. A total of 127 patients (12.4%) with an NLR of 4.0 or more were classified as high NLR individuals in this study. The prognostic significance of a high NLR, together with various clinicopathological factors, was evaluated by multivariate analysis.ResultsThe 5-year survival of patients with a high NLR was significantly worse than that of patients with a low NLR (57% vs 82%, P < 0.001). Univariate and multivariate analyses of clinicopathological factors affecting survival revealed that high NLR, depth of tumor, positive lymph nodes, distant metastasis, peritoneal metastasis, poorly differentiated type, and high platelet count were significant risk factors for reduced survival. On multivariate analysis, after adjusting for tumor stage, a high NLR was an independent risk factor for reduced survival (P = 0.003; adjusted hazard ratio, 1.845; 95% confidence interval, 1.236–2.747).ConclusionA high preoperative NLR may be a convenient biomarker to identify patients with a poor prognosis after resection for primary gastric cancer.

Comparison of laparoscopy-assisted and open pylorus-preserving pancreaticoduodenectomy for periampullary disease

BACKGROUND Although many reports have described laparoscopic pancreatic surgery, pancreaticoduodenectomy (PD) has not been widely accepted. The present study aimed to compare laparoscopy-assisted and open pylorus-preserving pancreaticoduodenectomy (PPPD) to investigate the feasibility, safety, and tumor clearance. METHODS Fifteen patients with periampullary disease underwent laparoscopy-assisted PPPD, in which resection was performed laparoscopically and the reconstruction was performed through a small midline incision. These patients were compared with 15 patients who, during the same period, underwent conventional open PPPD. RESULTS Mean operative time and mean blood loss were similar between groups. No significant differences in the incidence of complications or hospital stay were noted between groups. Surgical margin and number of lymph nodes found in the resected specimen did not differ between groups. CONCLUSIONS Laparoscopy-assisted PPPD is on the same level with conventional open surgery in terms of perioperative outcomes or treatment efficacy.

Laparoscopy-assisted hepatic lobectomy using hilar Glissonean pedicle transection

Although many reports have described laparoscopic minor liver resections, major hepatic resection, including right or left lobectomy, has not been widely developed because of technical difficulties. This article describes a new technique for performing laparoscopy-assisted right or left hepatic lobectomy using hilar Glissonean pedicle transection. Laparoscopic mobilization of the right or left hepatic lobe is performed, including dissection of the round, faliciform, triangular, and coronary ligaments. The right or left Glissonean pedicle is encircled and divided laparoscopically. A parenchymal dissection is then performed though the upper median or right subcostal incision, through which the resected liver is removed. We successfully performed this procedure in 6 patients without blood transfusion or serious complications. Laparoscopy-assisted hepatic lobectomy using hilar Glissonean pedicle transection can be feasible and safe in highly selected patients.

Renal cell carcinoma with unusual metastasis to the gallbladder

Gallbladder involvement in patients with renal cell carcinoma (RCC) is extremely rare. We present a report of a 61-year-old man with a synchronous RCC metastasis to the gallbladder presenting as an intraluminal polypoid mass simulating primary gallbladder carcinoma. Enhanced abdominal computed tomography demonstrated a well-enhanced polypoid lesion in the gallbladder. Intraoperative rapid pathological examination of the gallbladder tumor showed clear cell-type cancerous cells. Microscopically, tumor cells of both the resected kidney and gallbladder had round uniform nuclei, clear cytoplasm, and well-defined cytoplasmic borders, forming alveolar patterns. Immunohistochemically, the tumor cells were negative for cytokeratin 7 (CK7) and carcinoembryonic antigen (CEA), which is usually positive in primary clear cell carcinoma of the gallbladder. Therefore, the final diagnosis was RCC with a synchronous gallbladder metastasis.

Relation between Hepatic and Portal Veins in the Right Paramedian Sector: Proposal for Anatomical Reclassification of the Liver

Although a right liver graft without a middle hepatic vein resulted in potential venous congestion in the right paramedian sector, the details of the hepatic venous distribution in the right paramedian sector have not been established. In this study, the ramification patterns of the hepatic veins draining the right anterosuperior segment (S8) and the relation between the hepatic and portal veins were assessed using multislice computed tomography in 44 patients without lesions in the liver. All 52 drainage veins of the ventral area of S8 joined the middle hepatic vein, and all 48 drainage veins of the dorsal area joined the right hepatic vein. The hepatic vein crossing between the ventral and dorsal areas was observed in each patient examined. Therefore, we propose a reclassification wherein the right paramedian sector is divided into ventral and dorsal segments. This new classification may contribute to the development of new and safer surgical procedures, including more limited resection and right lobe adult living donor liver transplantation to avoid graft congestion.

A Totally Laparoscopic Pylorus-Preserving Pancreaticoduodenectomy and Reconstruction

AbstractAlthough many reports have described laparoscopic pancreatic surgery, laparoscopic pancreaticoduodenectomy (PD) has not been widely employed because of technical difficulties. This paper describes a totally laparoscopic pylorus-preserving PD performed for an intraductal papillary-mucinous neoplasm. After the laparoscopic resection, an end-to-side pancreaticojejunostomy including duct-to-mucosa anastomosis without a stenting tube, an approximation of the pancreas stump and jejunal wall, an end-to-side hepaticojejunostomy, and an end-to-side duodenojejunostomy were performed intracorporeally. The patient recovered without any complications and was discharged on the 14th postoperative day. The surgical margin was free of neoplastic changes. Although the experience is limited and the appropriate indications must await future studies, this case indicates that a laparoscopic pylorus-preserving PD can be feasible, safe, and effective in highly selected patients.

Safe and feasible extrahepatic Glissonean access in laparoscopic anatomical liver resection.

BackgroundAlthough recent technological developments and improved endoscopic procedures have further spread the application of laparoscopic liver resection, laparoscopic anatomical liver resection still presents major technical difficulties, such as pedicle control.MethodsSubjects comprised 27 patients who underwent laparoscopic anatomical liver resection using an extrahepatic Glissonean pedicle transaction between August 2005 and February 2010.ResultsA total of 61 Glissonean pedicles could be encircled en bloc extrahepatically, as planned. No serious complications, including major bleeding or injury of the portal triad, were encountered during procedures.ConclusionsExtrahepatic Glissonean access seems to be feasible and safe for laparoscopic anatomical resection of the liver.

Safe and feasible inflow occlusion in laparoscopic liver resection

Background A major challenge in laparoscopic liver resection to avoid massive hemorrhage from the transection plane.

Laparoscopic major hepato-biliary-pancreatic surgery: formidable challenge to standardization

INTRODUCTION Although laparoscopic colorectal or gastric surgery has become widely accepted as a superior alternative to conventional open surgery, the surgical management of hepato-biliary-pancreatic disease has traditionally involved open surgery. Recently, many reports have described laparoscopic partial liver resection, lateral segmentectomy, and distal pancreatectomy. However, laparoscopic major hepato-biliary-pancreatic surgery, such as hepatic lobectomy and pancreaticoduodenectomy, has not been widely developed because of technical difficulties. METHODS We describe our experience with laparoscopic major hepato-biliary-pancreatic surgery, including right hepatectomy using hilar Glissonean pedicle transaction, and pylorus-preserving pancreaticoduodenectomy. CONCLUSION Although our experience is limited, and randomized study is necessary to elucidate the appropriate indications for and effects of the present procedures, we believe that laparoscopic major hepato-biliary-pancreatic surgery can be feasible, safe, and effective in highly selected patients, and that it will be one of the standard therapeutic options for carefully selected patients with hepato-biliary-pancreatic disease.

Performing simple and safe dunking pancreaticojejunostomy using mattress sutures in pure laparoscopic pancreaticoduodenectomy.

BackgroundAlthough recent technological developments and improved endoscopic procedures have further spread the application of laparoscopic pancreatic resection, laparoscopic pancreaticoduodenectomy still presents major technical difficulties, such as when performing pancreatic–enteric anastomosis.MethodsLaparoscopic dunking pancreaticojejunostomy using mattress sutures was performed in 15 consecutive patients with a soft pancreas and a nondilated pancreatic duct between October 2011 and December 2012.ResultsAccording to the International Study Group on Pancreatic Fistula criteria, 3 patients developed PF (grade A), whereas the remaining 12 patients did not.ConclusionsDunking pancreaticojejunostomy using mattress sutures is considered to be a feasible and safe method for performing pure laparoscopic pancreaticoduodenectomy.