Atsushi Toma

Outcome of prophylactic radical lymphadenectomy with gastrectomy in patients with early gastric carcinoma without lymph node metastasis

Prophylactic extended lymphadenectomy with gastrectomy may prolong survival in patients with early gastric carcinoma without lymph node metastasis. However, the therapeutic value of extensive lymphadenectomy in patients with early gastric carcinoma remains controversial.

Long-term benefit of extended lymphadenectomy with gastrectomy in distally located early gastric carcinoma

BACKGROUND Extended lymphadenectomy performed with gastrectomy has been reported to prolong survival of patients with early gastric cancer. However, some authors question the value of extensive lymphadenectomy in these patients, especially since much recent discussion of patient quality of life after gastrectomy has favored less invasive operations. METHODS We retrospectively analyzed 485 patients who had undergone gastrectomy for early cancer in order to evaluate the effect of extended versus limited lymphadenectomy on postoperative survival. Various prognostic factors were examined for patients whose tumors were located in the distal third of the stomach. RESULTS Although extended radical lymphadenectomy did not prolong postoperative survival when early gastric cancer was located in the middle or proximal third of the stomach, it did when the tumor occupied the distal third. CONCLUSIONS Performance of extended radical lymphadenectomy was a significant prognostic factor for early gastric cancer patients when tumors were located in the distal third of the stomach.

Mesohepatectomy with total caudate lobectomy of the liver for hepatocellular carcinoma.

BackgroundMesohepatectomy with total resection of the caudate lobe and extrahepatic bile duct is sometimes performed for hilar cholangiocarcinoma or gallbladder carcinoma; however, only a few reports on mesohepatectomy with total caudate lobectomy of the liver for hepatocellular carcinoma are available.MethodsA 71-year-old woman was preoperatively diagnosed with hepatocellular carcinoma in the central bisections (Couinaud’s segments 4, 5, and 8) and the paracaval portion of the caudate lobe. Mesohepatectomy with total caudate lobectomy of the liver permitted the removal of tumors to provide a cancer-free raw surface of the liver. Mobilization of the caudate lobe is an important procedure in this surgery. Before the liver parenchyma was dissected, all short hepatic veins were ligated and divided from the left to the right side as the left lateral section was retracted to the right, and the caudate lobe branches of the portal vein and hepatic artery were ligated and divided. After the liver parenchymal dissection, both between the left lateral and medial sections and between the right anterior and posterior sections, the Glissonean branches of the caudate lobe were ligated and divided as the central bisections were anteriorly retracted. Finally, liver parenchymal dissection was performed between the caudate lobe and the right posterior section, which was along the right side of the inferior vena cava.ResultsThe surgery time was 538 minutes and blood loss was 1,207 mL. No blood transfusions were required during or after surgery. The postoperative course was uncomplicated. The patient is still alive 25 months after hepatectomy.ConclusionAlthough mesohepatectomy with total caudate lobectomy of the liver is technically more difficult than mesohepatectomy of the liver because the caudate lobe must be completely detached from the inferior vena cava and the hilar plate, it is a safe and effective treatment method in selected patients with hepatocellular carcinoma located at both the central bisections and the paracaval portion of the caudate lobe.

Anatomical liver segmentectomy 2 for combined hepatocellular carcinoma and cholangiocarcinoma with tumor thrombus in segment 2 portal branch

BackgroundHepatic resection is the only effective treatment for combined hepatocellular carcinoma and cholangiocarcinoma.Case presentationA 52-year-old man was preoperatively diagnosed with hepatocellular carcinoma in segment 2 with tumor thrombus in the segment 2 portal branch. Anatomical liver segmentectomy 2, including separation of the hepatic arteries, portal veins, and bile duct, enabled us to remove the tumor and portal thrombus completely. Modified selective hepatic vascular exclusion, which combines extrahepatic control of the left and middle hepatic veins with occlusion of left hemihepatic inflow, was used to reduce blood loss. A pathological examination revealed combined hepatocellular carcinoma and cholangiocarcinoma with tumor thrombus in the segment 2 portal branch. No postoperative liver failure occurred, and remnant liver function was adequate.ConclusionThe separation method of the hepatic arteries, portal veins, and bile duct is safe and feasible for a liver cancer patient with portal vein tumor thrombus. Modified selective hepatic vascular exclusion was useful to control bleeding during liver transection. Anatomical liver segmentectomy 2 using these procedures should be considered for a patient with a liver tumor located at segment 2 arising from a damaged liver.

A Case of Neuroendocrine Cell Carcinoma with Sigmoidovesical Fistula.

Colonic neuroendocrine cell carcinoma (NEC), which is a rare subtype of colon epithelial neoplasm, has been reported to show extremely aggressive characteristics with a 1-year survival rate of 20%. We report herein a resected case of NEC that manifested bacterial sepsis due to sigmoidovesical fistula. Staged surgery consisted of resecting the sigmoid colon and part of the bladder four weeks after construction of an ileostomy to alleviate septic shock. The resected specimen was histologically diagnosed as NEC invading the wall of the urinary bladder with metastasis to the regional lymph nodes. The patient underwent four cycles of FOLFOX after surgery for additional treatment of residual metastatic lymph nodes around the abdominal aorta diagnosed preoperatively. Although the patient showed stable disease measured by computed tomography scan for the first three months after surgery, he rejected additional chemotherapy thereafter, and died ten months after the initial admission due to progression of residual tumor in the urinary bladder as well as the lymph nodes. This is the first case report describing colonic NEC manifesting perforation into the urinary bladder. Although the optimal chemotherapeutic regimen for colonic NEC has not yet been established, FOLFOX may be one of the choices.