Etsuro Bando

Intraoperative lavage for cytological examination in 1,297 patients with gastric carcinoma

BACKGROUND This study examined the clinical value of intraoperative peritoneal lavage for cytological examination in patients with gastric cancer. Peritoneal dissemination is the most frequent mode of recurrence for this tumor. METHODS A retrospective of lavage findings, other factors, and outcome was performed in 1,297 patients with gastric cancer who underwent intraoperative peritoneal lavage. RESULTS The 5-year survival rate of patients with positive lavage cytology was only 2%. Patients who underwent curative resection and had negative cytology had a significantly better 5-year survival rate (P < 0.001). Even among patients with macroscopic peritoneal dissemination, the survival rate was significantly better with negative cytology, which reflected fewer free cancer cells in the peritoneal cavity. Serum concentrations of carcinoembryonic antigen and carbohydrate antigen 19-9 were significantly higher in patients with positive cytology. Multivariate analyses indicated that intraoperative cytological findings was an independent prognostic factor for survival, and was the most important factor for predicting peritoneal recurrence. CONCLUSIONS Intraoperative peritoneal lavage cytology is important in predicting survival and peritoneal recurrence in gastric cancer.

Outcome of ratio of lymph node metastasis in gastric carcinoma.

BackgroundThe purpose of this study was to clarify the outcome of the ratio of the metastatic lymph nodes (RML) in gastric cancer patients.MethodsThe postoperative survival of 650 patients with gastric cancer who underwent D2 curative gastrectomy was analyzed with regard to the RML. The location, number, and RML in the N1 station and in all (N1 and N2) stations were analyzed. These data were compared from the viewpoints of staging accuracy and patient survival.ResultsThe RML was classified as follows: RML 0, no involvement; RML 1, 0 to .1; RML 2, .1 to .25; and RML 3, ≥.25. The 5-year survival rates stratified by RML were RML 0, 86%; RML 1, 68%; RML 2, 35%; and RML 3, 16%. Cox model identified all methods of classifying lymph node metastases as independent prognostic indicators in each calculation. However, a second Cox regression revealed that RML was the only independent prognostic factor among the three methods (P<.001). Stage migration was present in 35 cases (15%) when the number was considered. However, only 15 cases (7%) were underdiagnosed when RML was used.ConclusionsRML is a useful classification of patients with gastric cancer. It may prevent the phenomenon of stage migration.

Omental Flap in Pancreaticoduodenectomy for Protection of Splanchnic Vessels

Intraabdominal bleeding, the most life-threatening complication following pancreaticoduodenectomy (PD), most often is associated with failure of a pancreaticojejunostomy anastomosis or with intraabdominal infection. We investigated whether placement of an omental flap around the splanchnic vessels in PD could reduce the occurrence of intraabdominal bleeding and other postoperative complications. One hundred consecutive patients who underwent PD at the authors’ institution between January 2000 and October 2004 were enrolled in this prospective study. After dissection of the hepatoduodenal ligament, the major splanchnic arteries and the portal vein were covered by the omental flap. Preoperative condition, incidence of pancreatic fistula, intra-abdominal bleeding, other complications, treatment mortality, and hospital stay were analyzed for interrelationships. The frequency of pancreatic fistula (20%) differed little from those in previous reports. However, intraabdominal bleeding was observed in only 1 (1.0%) patient, who was considered to have too thin a flap. No intraabdominal abscess was encountered. No mortality or complications occurred in relation to the omental flap. Thus, wrapping an omental flap around dissected splanchnic vessels in PD reduced postoperative intraabdominal bleeding and infection, but failed to prevent pancreatic fistulas.

Sentinel lymphadenectomy in breast cancer: identification of sentinel lymph node and detection of metastases.

Sentinel lymphadenectomy is a useful way of assessing axillary status and obviating axillary dissection in patients with node-negative breast cancer. However, controversies remain concerning the optimal method to identify the sentinel lymph node (SLN) and detect micrometastases in this lymph node. We reviewed the literature concerning sentinel lymphadenectomy in breast cancer and reached the following conclusions: (a) A combination of preoperative lymphoscintigraphy with intraoperative dye-guided and gamma probe-guided methods achieves a higher rate of identification of SLN than any of these techniques alone. (b) Immediate and reliable intraoperative assessment of sentinel node status is vital to the techniques success. However, the reliability of sentinel node diagnosis using frozen sections is questionable, because micrometastatic foci cannot always be identified. (c) Hematoxylin and eosin (H&E) staining and/or immunohistochemistry on permanent sections are useful for the detection of micrometastases in the sentinel node. Although a reverse transcriptase–polymerase chain reaction (RT–PCR) method is more sensitive than H&E staining and immunohistochemistry, it would not distinguish benign from malignant epithelial cells in the SLN.Therefore, further study is required before sentinel lymphadenectomy gains general acceptance for patients with primary breast cancer.

Staging efficacy of breast cancer with sentinel lymphadenectomy

Seventy‐two patients underwent dye‐guided or dye‐ and gamma probe‐guided sentinel lymphadenectomy (SLND) followed by complete axillary lymph node dissection (ALND). The results of imprint cytology, frozen sections, and permanent sections of the sentinel lymph node (SLN) were compared to each other and to the histologic findings in the nonsentinel nodes. The SLN was identified in 62 (88%) of 72 patients. Evaluation of the SLN on the permanent sections yielded a diagnostic accuracy of 95%, a sensitivity of 89%, and a specificity of 100, although the reliability of SLN diagnosis using frozen sections or imprint cytology is limited. Therefore, it may be concluded that SLND with multiple sectioning and histopathologic examination of the SLNs can predict the presence or absence of axillary‐node metastases in patients with breast cancer. However, further studies will be needed to investigate the value of SLND in respect to the long‐term regional control and any possible detriment or benefit to survival, before it can replace routine ALND as the preferred staging operation for operable breast cancer.

Intra-abdominal infectious complications following gastrectomy in patients with excessive visceral fat

BackgroundExcessive visceral fat may be a better predictor of the development of postoperative morbidity after gastrectomy than body mass index (BMI). The aim of the present study was to clarify the most appropriate fat parameter to predict pancreas-related infection and anastomotic leakage following gastrectomy.MethodsThe study was performed in 206 patients who underwent curative gastrectomy at the Shizuoka Cancer Center between April 2008 and March 2009. Relationships between fat parameters, including visceral fat area (VFA), and early surgical outcomes were investigated. The risk factors for pancreas-related infection and anastomotic leakage were identified using univariate and multivariate analyses.ResultsThere was no strong association between any of the fat parameters and operating time, intraoperative blood loss, the number of lymph nodes retrieved, or the duration of the postoperative hospital stay. Pancreas-related infection occurred in 18 patients (8.7%), whereas anastomotic leakage was observed in 10 patients (4.9%). Of all the fat parameters, only VFA was found to be an independent risk factor for both pancreas-related infection and anastomotic leakage, with odds ratios (95% confidence intervals) of 1.015 (1.005–1.025) and 1.010 (1.000–1.021), respectively.ConclusionsExcessive visceral fat, represented by the VFA, was found to be an independent risk factor for both pancreas-related infection and anastomotic leakage following gastrectomy.

Dye- and gamma probe-guided sentinel lymph node biopsy in breast cancer patients: using patent blue dye and technetium-99m-labeled human serum albumin.

BackgroundSentinel lymph node (SLN) biopsy is a promising method for the diagnosis of the axillary nodal status. We examined the availability of the SLN biopsy using two mapping procedures: the dye- and gamma probe-guided method, and preoperative lymphoscintigraphy by gamma camera imaging.MethodsWe enrolled 48 patients with breast cancer. Technetium-99m-labeled human serum albumin was injected into the subdermal tissue above the primary tumor or biopsy cavity, and preoperative gamma camera imaging was performed. After induction of general anesthesia, patent blue dye was injected into the peritumoral area prior to the surgical procedure. A handheld gamma-detection probe was used to assist in SLN detection. Careful dissection was performed to identify blue-stained afferent lymphatic vessels and nodes. An SLN was defined as any blue and/or radioactive node, and was excised. After SLN biopsy, axillary lymph node dissection of level I, II, and III was completed, in order to confirm the diagnostic ability of the SLN biopsy.ResultsIntraoperative SLN identification of axillary lesions was successful in 43 of 48 patients (90%). The dye- and gamma probe-guided method was successful in 25 patients (52%), the dye-guided method alone succeeded in 11 patients (23%), and the gamma probe-guided method alone succeeded in 7 patients (15%). Preoperative lymphoscintigraphy revealed axillary focal accumulations in 29 of 48 patients (60%). All patients who underwent successful preoperative SLN identification by lymphoscintigraphy had successful intraoperative SLN identification. A diagnostic accuracy of 95%, a sensitivity of 89%, and a specificity of 100% were achieved in the diagnosis of axillary metastasis. Internal mammary SLNs were identified in four patients intraoperatively, but we could not detect cancer metastasis in the internal mammary SLNs.ConclusionsThe dye-guided and gamma probe-guided methods were complementary. Preoperative lymphoscintigraphy was useful to predict intraoperative SLN identification. Further study is necessary to assess the role of SLN biopsy of the internal mammary lymph nodes.

Pancreatic-type mixed acinar-endocrine carcinoma with alpha-fetoprotein production arising from the stomach: a report of an extremely rare case

An extremely rare case of mixed acinar-endocrine carcinoma (MAEC) arising from the stomach in a 56-year-old Japanese woman is herein presented. An endoscopic examination and computed tomography showed a protruding gastric tumor and a large extragastric mass, respectively. Macroscopic observation on the surgical specimen revealed the extragastric cystic mass was continued to the intragastric tumor. Histologically, the intragastric tumor consisted of large or small solid nests with acinar appearance. The cancer cells had an ovoid nuclei and polygonal cytoplasm, which was frequently amphophilic. Immunohistochemical examination showed that the cancer cells were positive for chromogranin-A, synaptophysin, alpha-amylase, lipase, and alpha-fetoprotein (AFP) but were negative for CD56, insulin, and other hormones. Ultrastructurally, the cancer cells contained 500-nm electron-lucent zymogen granules and 230-nm electron-dense neuroendocrine granules. This tumor was finally diagnosed to be MAEC with AFP production of the stomach. Although no ectopic pancreas was found in the stomach, this tumor may originate from ectopic pancreas. As another theory, it is possible for this tumor to originate from the pluripotent stem cells in the stomach. A gastric MAEC with AFP production has not been reported previously.

Intestinal Obstruction in the Terminal Ileum Caused by an Anomalous Congenital Vascular Band Between the Mesoappendix and the Mesentery: Report of a Case

We report a case of intestinal obstruction caused by a congenital abnormal vascular band in a 17-year-old boy. The patient was admitted with acute colicky abdominal pain, and an emergency laparotomy revealed that the ileum was strangulated by a fibrous band with vessels about 2 mm in diameter and 7 cm in length, extending from the antemesenterium of the terminal ileum to the mesoappendix. The affected intestine was resected with the band and the appendix. Histologically, the fibrous band was composed of loose connective tissue containing arteries, veins, and nerve fibers, suggesting that it was congenital and originated from a remnant of the ventral mesentery in the embryonic period. There have been few reports of intestinal obstruction being caused by a congenital vascular band, especially in patients beyond the pediatric age group.

Robotic surgery for gastric cancer

Laparoscopic gastrectomy is a widely used minimally invasive surgery for gastric cancer. However, skillful techniques are required to perform lymph node dissection using straight shaped forceps, particularly for D2 dissection. Robotic surgery using the da Vinci surgical system is anticipated to be a powerful tool for performing difficult techniques using high-resolution three-dimensional (3D) images and the EndoWrist equipped with seven degrees of freedom. Attempts are being made to apply robotic surgery in gastrectomy procedures mainly in Japan, South Korea, and Europe. Although definite superiority to laparoscopic gastrectomy is yet to be proven, robotic surgery has been reported to have a shorter learning curve and offer more precise dissection for total gastrectomy. Hence, its oncological efficacy needs to be verified in a clinical trial.