Hideki Aoki

Milk-based test as a preventive method for chylous ascites following pancreatic resection.

Background/Purpose: The incidence and natural history of postoperative chylous ascites are not well understood. This complication causes malnutrition and prolonged hospital stay. We investigated our institution’s experience involving chylous ascites, especially following pancreatectomy. Additionally, we designed a new intraoperative method dubbed the ‘milk test’ for preventing chylous ascites. Methods: Five cases of chylous ascites following pancreatectomy from April 2001 through March 2004 were studied retrospectively. The milk test was carried out prospectively. Such rates as positivity and incidence of ascites were examined. Results: Of 65 cases (40 pancreatoduodenectomy; 25 distal pancreatectomy), 5 (7.7%) developed chylous ascites following pancreatic resection. All cases underwent octreotide and total parenteral nutrition treatment. From April 2004 through March 2009, the milk test was used in 104 cases. Surgical procedures comprised pancreatoduodenectomy (n = 78) and distal pancreatectomy (n = 23). Of these cases, 23 (22.1%) tested positive. No significant difference in positive rates was observed between the procedures and diseases. After initiation of the milk test, chylous ascites incidence decreased from 7.7 to 2.9%. Conclusions: For chylous ascites, octreotide and total parenteral nutrition treatments are useful. However, the milk test was found to be a safe and effective method for prevention of chylous ascites following pancreatectomy.

Postsurgical Intrahepatic Portal Thromboembolism: A Possible Cause of Perfusion Defects on Ct during Arterial Portography

Objective Our goal was to investigate unexplained nontumorous perfusion defects on CT arterial portography (CTAP). Materials and Methods The CTAP images of 35 patients who underwent partial hepatectomy or open biopsy were analyzed. Hepatic tumors consisted of hepatocellular carcinoma (n = 18) and colorectal carcinoma metastases (n = 17). Nontumorous perfusion defects were categorized into those previously explained and those unexplained. We investigated unexplained ones and their relationship with the underlying conditions. Results Eight unexplained nontumorous perfusion defects were found in four patients with colorectal metastases. Statistical analysis showed that the defects occurred with significantly higher incidence in patients with colorectal metastases than in those with hepatocellular carcinoma (p = 0.046, Fisher test). All four patients with defects underwent CTAP within 1 month after colorectal surgery. A significant difference was seen in the distribution of surgery-CTAP time intervals between those patients with and those without defects (p < 0.05, Wilcoxon-Mann-Whitney test). Intrahepatic portal thrombi were pathologically proven in one of the four patients.Conclusion: Unexplained nontumorous hepatic perfusion defects tnay represent postsurgical portal thromboemboli. Index Terms Colon, neoplasms—Liver—Liver, blood supply—Liver, neoplasms—Angiography—Computed tomography.

Primary hepatic leiomyosarcoma with liver metastasis of rectal cancer

Primary hepatic leiomyosarcoma is a particularly rare tumor with a poor prognosis. Curative resection is currently the only effective treatment, and the efficacy of chemotherapy is unclear. This represents the first case report of a patient with primary hepatic leiomyosarcoma co-existing with metastatic liver carcinoma. We present a 59-year-old man who was diagnosed preoperatively with rectal cancer with multiple liver metastases. He underwent a curative hepatectomy after a series of chemotherapy regimens with modified FOLFOX6 consisting of 5-fluorouracil, leucovorin and oxaliplatin plus bevacizumab, FOLFIRI consisting of 5-fluorouracil, leucovorin and irinotecan plus bevacizumab, and irinotecan plus cetuximab. One of the liver tumors showed a different response to chemotherapy and was diagnosed as a leiomyosarcoma following histopathological examination. This case suggests that irinotecan has the potential to inhibit the growth of hepatic leiomyosarcomas. The possibility of comorbid different histological types of tumors should be suspected when considering the treatment of multiple liver tumors.

Evaluation of surgical treatment for incidental gallbladder carcinoma diagnosed during or after laparoscopic cholecystectomy: single center results

BackgroundLaparoscopic cholecystectomy (LC) is the accepted standard management for benign gallbladder disease. LC rarely results in a diagnosis of incidental gallbladder carcinoma (IGBC). The aim of our study was to report our experience with IGBC diagnosed during or following LC.MethodsBetween January 2008 and January 2015, 352 patients underwent LC at Iwakuni Clinical Center. Among these patients, 8 (2.3%) were diagnosed with IGBC. We evaluated their characteristics, surgical related variables, histopathological findings and surgical outcomes.ResultsPatient median age was 71 (range 49–88) years, and 3 out of 8 were female. All patients with IGBC were Japanese. The grade of cancer was as follows: pT1a (3 cases), pT2 (4 cases) and pT3 (1 case). Two patients with pT2 disease underwent radical surgery. The median follow-up time of these patients was 24 (range 11–80) months. All patients are still alive and two of three patients who refused radical surgery have developed recurrence (liver metastases and recurrence in the peritoneum).ConclusionsAlthough the number of cases was small, the results of this study further support the suggestion that gallbladder carcinoma may be curable if diagnosed as IGBC at an early stage. If the cancer has reached an advanced stage, radical surgery should be performed.

Synchronous coexistence of liver metastases from cecal leiomyosarcoma and rectal adenocarcinoma: A case report

Multiple liver tumors represent a challenging condition for abdominal surgeons both in the selection of technique and the rarity of diagnosis. There are no case reports on co-existence of liver metastases from both intestinal leiomyosarcoma and adenocarcinoma. The patient described in this report successfully underwent resection of both primary lesions and liver metastases in combination with chemotherapy. As for the leiomyosarcoma, the primary cecal lesion was revealed more than three years after the patients first visit. Peritoneal, lymph-node, and lung recurrences were observed afterward, and thus surgeries on those regions were performed. Pathologically, the peritoneal and lung recurrences comprised leiomyosarcoma and the lymph-node recurrence was diagnosed as adenocarcinoma. Despite newly discovered multiple lung recurrences and regional lymph-node metastases, the patient lived a normal life for 73 mo after the initial operation based on multidisciplinary therapy. He ultimately died of liver failure due to invasive lymph-node recurrence from the rectal adenocarcinoma, in addition to multiple lung recurrences from the leiomyosarcoma. Hepatic recurrence did not occur in this patients case, which appears to be one reason for his long-term survival.

Changes over time in milk test results following pancreatectomy

AIM To investigate changes over time in, and effects of sealing technology on, milk test results following pancreatectomy. METHODS From April 2008 to October 2013, 66 pancreatic resections were performed at the Iwakuni Clinical Center. The milk test has been routinely conducted at the institute whenever possible during pancreatectomy. The milk test comprises the following procedure: A nasogastric tube is inserted until the third portion of the duodenum, followed by injection of 100 mL of milk through the tube. If a chyle leak is present, the patient tests positive in this milk test based on the observation of a white milky discharge. Positive milk test rates, leakage sites, and chylous ascites incidence were examined. LigaSure™ (LS; Covidien, Dublin, Ireland), a vessel-sealing device, is routinely used in pancreatectomy. Positive milk test rates before and after use of LS, as well as drain discharge volume at the 2(nd) and 3(rd) postoperative days, were compared retrospectively. Finally, positive milk test rates and chylous ascites incidence were compared with the results of a previous report. RESULTS Fifty-nine milk tests were conducted during pancreatectomy. The positive milk test rate for all pancreatectomy cases was 13.6% (8 of 59 cases). One case developed postoperative chylous ascites (2.1% among the pancreatoduedenectomy cases and 1.7% among all pancreatectomies). Positive rates by procedure were 12.8% for pancreatoduodenectomy and 22.2% for distal pancreatectomy. Positive rates by disease were 17.9% for pancreatic and 5.9% for biliary diseases. When comparing results from before and after use of LS, positive milk test rates in pancreatoduodenectomy were 13.0% before and 12.5% after, while those in distal pancreatectomy were 33.3% and 0%. Drainage volume tended to decrease when LS was used on the 3(rd) postoperative day (volumes were 424 ± 303 mL before LS and 285 ± 185 mL after, P = 0.056). Both chylous ascites incidence and positive milk test rates decreased slightly compared with those rates from the previous study. CONCLUSION Positive milk test rates and chylous ascites incidence decreased over time. Sealing technology may thus play an important role in preventing postoperative chylous ascites.

Surgical resection of splenic metastasis from the adenosquamous gallbladder carcinoma: A case report

Highlights • We report a case of splenic metastasis of adenosquamous carcinoma of gallbladder.• Splenic metastasis of adenosquamous gallbladder carcinoma is a rare.• Resection of splenic metastasis may represent the treatment for prolonging survival.

Study on the Clinicopathological Characteristics and the Prognosis after Hepatic Resection of Hepatocellular Carcinoma with Simultaneously Multiple Nodules.

1985年1月から1995年12月までに肝切除を施行した肝細胞癌67例を, 肝癌取扱い規約でいう初期の高分化肝細胞癌, 境界病変を有する境界病変併存群(BL群)12例, 肝内転移群 (IM群) 11例, 多中心性発生群 (MO群) 3例と, 単発群 (St群) 41例とに分け各群の臨床病理学的特徴ならびに切除後予後を比較検討した. BL群, MO群はIM群, St群に比べ肝硬変が高率にみられた. 肝細胞癌と併存病変は, BL群, MO群に比べIM群では同一区域に存在する頻度が高かった. 門脈浸潤はIM群が他群に比べ高率であった. 生存率はSt群, BL群はIM群に比べ良好であるが, St群,BL群でも門脈浸潤陽性例では2年以内の再発が高率であった. St群の5年無再発生存率は45.8%で, BL群は3年以内に,IM群は2年以内に全例再発した. 以上のことから多中心発生群, 境界病変併存群は肝硬変の頻度が高く, その切除後予後は肝内転移群にくらべ良好であるが, 残肝再発率は高いことが示唆された.

A Case of Hyperammonemia and Coma Induced by Sodium Valproate after Hepatectomy for Liver Metastasis.

転移性肝癌に対する肝切除後, sodium valproate (VPA) による高アンモニア血症と昏睡をきたした1例について報告する.症例は50歳の男性で既往歴として脳梗塞があり, その後抗てんかん剤としてVPAを服用していた.肝切除後の経過は良好で術後4口目から食事が始まり, ラクツロースとともにVPAも再開された.ラクツロース中止後4日目から全身倦怠感出現し, 5日目には昏睡に陥った.この時点での肝機能所見および脳computed tomographyでは異常はないが, アンモニアが異常に高く, 薬剤副作用による高アンモニア血症に伴う昏睡が疑われた.VPAの投与中止, ラクツロース, morihepaminの投与により2日目には意識が清明となった.アンモニアはVPAを投与していた術前より高く, 投与中止中の術直後一過性に上昇した後減少し, VPAの再開とともに再上昇した.アミノ酸分析ではVPA投与時にはアルギニンの低下がみられ, 昏睡はVPAおよび肝切除による尿素回路抑制の結果生じたものと考えられた.

Significance and Problems of Hepatic Resection for Hepatocellular Carcinoma and Borderline Lesions in Terms of Recurrence in the Remnant Liver.

肝細胞癌とともにangio CTで確認された併存境界病変をも合併切除した場合の1年以内の残肝再発の状態からその切除の意義ならびに問題点を検討した. 対象20例で39病変が確認され, 初期の高分化肝細胞癌, 境界病変を含む多中心性発生を示唆する多発症例が11例 (55%) にみられた. 肝切除後1年以内の残肝再発は4例 (20%) であった. 単発例にくらべ多発例では残肝再発率が有意に高かった. 多発存在部位が反対葉のため相対的非治癒切除ないしエタノール注入におわり絶対非治癒切除になった場合, 残肝再発率が有意に高かった. 背景肝が肝硬変では慢性肝炎にくらべ残肝再発率が高かった. 残肝再発時には多発再発が多かった. 以上のことから肝細胞癌では, 多中心性発生が多いので, angio CTによる病変検索とそれにもとつく可及的切除により1年以内の残肝再発の減少が可能であった. 一方このように切除しても残肝再発時には切除不能な多発例が多く今後の検討課題と考えられた.