Hideyuki Kanemoto

Usefulness of positron emission tomography in the evaluation of distribution and activity of systemic lesions associated with autoimmune pancreatitis.

Background/Aims: Autoimmune pancreatitis (AIP) is an IgG4-related systemic disease often accompanied with a variety of lesions outside of the pancreas and is treated with steroid therapy. The aim of this study is to analyze the usefulness of positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET) in the evaluation of distribution and activity of systemic lesions of AIP during steroid therapy. Methods: Eleven cases of AIP had their FDG-PET images evaluated before and 3 months after steroid therapy and another 2 cases only before therapy. AIP activity was determined by the level of serum markers, IgG and IgG4, and compared with findings of PET. Results: In all 13 cases of AIP, a moderate to intense level of FDG accumulation was recognized in the pancreatic lesion before steroid therapy. Of 13 patients, 11 (84.6%) showed FDG accumulation in the multiple organs, such as mediastinal and other lymph nodes, salivary gland, biliary tract, prostate, and aortic wall. In 11 patients who underwent PET before and after steroid therapy, FDG accumulation was diminished in almost all systemic lesions, with a mean of maximum standardized uptake value (SUVmax) in the pancreatic lesion from 5.12 to 2.69. Similar to the SUV level, serum IgG and IgG4 were decreased in most of the cases after steroid therapy. Conclusions: FDG-PET is an effective modality to evaluate the response of steroid therapy and the distribution and activity of various systemic lesions of AIP.

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.

Serum CA19-9 is a Significant Predictor among Preoperative Parameters for Early Recurrence after Resection of Pancreatic Adenocarcinoma

ObjectiveTo evaluate the preoperative factors predictive of postoperative early recurrence in patients with resected pancreatic cancer focusing on the serum CA19-9 value.MethodsOne hundred fifty-four patients undergoing surgical resection for pancreatic cancer were enrolled in this study. Univariate and multivariate analyses were performed to determine the predictors of early recurrence which was defined as relapse within 6xa0months after surgery.ResultsOn ROC curve analysis, the cutoff value of CA19-9 was determined to be 100xa0U/ml. Of 73 patients with CA19-9 valueu2009≥u2009100xa0U/ml, 39 (53u2009%) had early recurrence. In contrast, only 9 of 81 patients (11u2009%) with CA19-9 valueu2009<u2009100xa0U/ml developed a recurrence at an early period (pu2009<u20090.001). Multivariate analysis revealed that CA19-9 valueu2009≥u2009100xa0U/ml (odds ratio, 11.2) were significant predictors of early recurrence. The overall 3- and 5-year survival rates and median survival times were 47.3u2009%, 40.1u2009%, and 31xa0months in patients with CA19-9 valueu2009<u2009100xa0U/ml and 21.2u2009%, 9.4u2009%, and 16xa0months in patients with CA19-9 valueu2009≥u2009100xa0U/ml (pu2009<u20090.001).ConclusionsA preoperative CA19-9 valueu2009≥u2009100xa0U/ml was a significant predictor of early recurrence and a poor prognosis after resection for pancreatic adenocarcinoma.

Margin status, recurrence pattern, and prognosis after resection of pancreatic cancer

BACKGROUNDnControversy persists as to whether positive operative margins are an independent prognostic factor for resected pancreatic cancer. This study evaluated the impact of the resection margin status on the patterns of recurrence and prognosis after resection for pancreatic cancer.nnnMETHODSnA total of 208 patients with pancreatic cancer who underwent resection with curative intent were studied retrospectively. All patients underwent pancreatectomy (164 pancreatoduodenectomies, 42 distal pancreatectomies, and 2 total pancreatectomies) intended to achieve R0 resection. They were divided into three groups on the basis of the following margin status: R(>1 mm), R(0-1 mm), and R(0 mm). The postoperative survival and recurrence patterns were evaluated in relation to the margin status. Multivariate analyses were performed to evaluate the factors influencing the overall survival.nnnRESULTSnThe resection margin was R(>1 mm) in 134 patients (65%), R(0-1 mm) in 40 (19%), and R(0 mm) in 34 patients (16%). The margin status correlated with the rate of local recurrence; 8% in R(>1 mm), 20% in R(0-1 mm), and 50% in R(0 mm) patients. In contrast, the incidence of recurrence at other sites, such as the lymph nodes, peritoneum, liver and other distant organs, were almost identical among the three groups. The median survival time was 26 months in R(>1 mm), 30 months in R(0-1 mm), and 23 months in R(0 mm) patients (P = not significant). The multivariate analyses revealed that lymph node metastases and poor differentiation were correlated with poor survival.nnnCONCLUSIONnIn the setting of pancreatectomy, when we evaluated the definitions of R0 resection, the margin status influenced the local recurrence rate but had no impact on the patients survival.

Risk Factor of Surgical Site Infection After Pancreaticoduodenectomy

BackgroundAlthough surgical site infection (SSI) following pancreaticoduodenectomy is a common complication, the risk factors remain unclear.Patients and methodsA retrospective study of 408 consecutive patients undergoing pancreaticoduodenectomy was conducted and the risk factors for SSI were assessed. The bacterial composition was also analyzed.ResultsSixty-one patients developed incisional SSI, and 195 developed organ/space SSI. A multivariate analysis identified that length of operation >480xa0min (odds ratio [OR] 3.22), main pancreatic duct (MPD) ≤3xa0mm (OR 2.18), and abdominal wall thickness >10xa0mm (OR 2.16) were significant risk factors for incisional SSI. The development of pancreatic fistula (OR 7.56), use of semi-closed drainage system (OR 3.68), body mass index >23.5xa0kg/m2 (OR 3.04), MPD ≤3xa0mm (OR 2.21), and length of operation >480xa0min (OR 1.78) were significantly associated with organ/space SSI. Bacterial isolation at the SSI foci revealed that gut-derived micro-organisms were the predominant bacterial species.ConclusionsThe presence of pancreatic fistula was the strongest risk factor for organ/space SSI. Efforts to reduce the development of pancreatic fistulas, to decrease length of operation, and to use a closed drainage system would decrease the incidence of SSI following pancreaticoduodenectomy. If SSI that requires antibacterial treatment occurs, then the treatment should target enterobacteria.

Risk factors of familial pancreatic cancer in Japan: Current smoking and recent onset of diabetes

Objectives: In western countries, 7% to 10% of patients with pancreatic cancer (PC) have a familial predisposition to their disease. The aim of this study was to determine the familial susceptibility to PC in Japan. Methods: Five hundred seventy-seven patients with PC and 577 age- and gender-matched controls were analyzed for cancer history in their first-degree relative(s) (FDRs) and demographic factors. Results: The patients with PC were more likely to have an FDR with PC (6.9%) than the controls (2.9%; odds ratio [OR], 2.5; P = 0.02). Three patients (0.5%), but none of the controls, had a family history of PC in multiple FDRs. Smoking, especially current smoking (OR, 1.5; P = 0.005), and diabetes mellitus (OR: 1.7, P = 0.001) were also associated with PC. The odds increased up to 10-fold if the patients were positive for these 3 factors. The patients with familial PC were more likely to be current smokers (40%) and to have diabetes mellitus (32.5%) than the sporadic cases (30.1% and 20.1%; OR, 1.6 and 1.9). Conclusions: A family history of PC is a risk of PC in Japan (6.9%) as is a personal history of diabetes and smoking. It is prudent to inform the kindred of patients with familiar PC of the risk of smoking and to follow carefully if they develop diabetes.Abbreviations: PC - pancreatic cancer, FDR - first-degree relative, OR - odds ratio, FPC - familial pancreatic cancer, DM - diabetes mellitus, SIR - standardized incidence rate, IPMN - intraductal papillary mucinous neoplasm, MDCT - multidetector computed tomography, US - ultrasound, NFPTR - National Familial Pancreas Tumor Registry

Risk of pancreatitis after endoscopic retrograde cholangiopancreatography and endoscopic biliary drainage

BACKGROUNDnPancreatitis is the most common and serious complication to occur after endoscopic retrograde cholangiopancreatography (ERCP). It is often associated with additional diagnostic modalities and/or treatment of obstructive jaundice. The aim of this study was to determine the risk of post-ERCP pancreatitis associated with pancreaticobiliary examination and endoscopic biliary drainage (EBD).nnnMETHODSnA total of 740 consecutive ERCP procedures performed in 477 patients were analysed for the occurrence of pancreatitis. These included 470 EBD procedures and 167 procedures to further evaluate the pancreaticobiliary tract using brush cytology and/or biopsy, intraductal ultrasound and/or peroral cholangioscopy or peroral pancreatoscopy. The occurrence of post-ERCP pancreatitis was analysed retrospectively.nnnRESULTSnThe overall incidence of post-ERCP pancreatitis was 3.9% (29 of 740 procedures). The risk factors for post-ERCP pancreatitis were: being female (6.5%; odds ratio [OR] 2.5, P= 0.02); first EBD procedure without endoscopic sphincterotomy (ES) (6.9%; OR 3.0, P= 0.003), and performing additional diagnostic procedures on the pancreatobiliary duct (9.6%; OR 4.6, P < 0.0001). Pancreatitis after subsequent draining procedures was rare (0.4%; OR for first-time drainage 16.6, P= 0.0003). Furthermore, pancreatitis was not recognized in 59 patients who underwent ES. Seven patients with post-EBD pancreatitis were treated with additional ES.nnnCONCLUSIONSnInvasive diagnostic examinations of the pancreaticobiliary duct and first-time perampullary biliary drainage without ES were high-risk factors for post-ERCP pancreatitis. Endoscopic sphincterotomy may be of use to prevent post-EBD pancreatitis.

Small-cell carcinoma in the common bile duct treated with multidisciplinary management

Small-cell carcinoma occasionally occurs in the gastrointestinal tract, with rare reports of it in the biliary system. When it does occur in the biliary system, it is mainly within the gallbladder, and those arising in the extrahepatic bile duct are extremely rare with only seven reported cases to date. A 62-year-old man with this unusual condition is documented. The patient was preoperatively diagnosed as having small-cell carcinoma on the basis of a biopsy specimen and was treated with multidisciplinary management, which consisted of preoperative chemotherapy, a curative resection, adjuvant chemotherapy, and radiation therapy. The patient died 23 months after the initial diagnosis (20 months after surgery). To the best of our knowledge, the survival time of this case was the longest among reported cases, and multidisciplinary management might contribute to a prolonged survival.

Negative impact of low body mass index on surgical outcomes after hepatectomy for hepatocellular carcinoma

BackgroundStudies have previously indicated that surgical outcomes are poorer for obese patients. To date, few reports concerning the effect of obesity on patient outcomes following a hepatectomy for hepatocellular carcinoma (HCC) have been published. The present study, therefore, sought to determine the impact of patients’ body mass index (BMI, kg/m2) on short- and long-term surgical outcomes and to identify potential prognostic factors for HCC following a hepatectomy.MethodsPatient data was retrospectively collected from 181 consecutive patients between September 2002 and August 2007 who had undergone hepatectomy for HCC with curative intent. Patients were assigned to three groups according to their BMI (low <18.5, standard 18.5–25, and high >25), and the clinical and pathological data, surgical outcome, and long-term survival were analyzed and compared between the three groups.ResultsThe overall survival rate of the low BMI group was notably below that of the standard group. Surgical outcomes were not significantly different between the three groups. Multivariate analysis revealed that a low BMI (<18.5) is a predictor of unfavorable prognosis.ConclusionsThe present study suggests that a low BMI is a significant prognostic factor for low overall survival when performing a hepatectomy for HCC.

Multiple Endocrine Neoplasms and Serous Cysts of the Pancreas in a Patient with von Hippel-Lindau Disease

IntroductionPatients with the von Hippel–Lindau (VHL) syndrome have an increased risk of developing pancreatic endocrine neoplasms.Case ReportA 40-year-old female with a past history of bilateral adrenal pheochromocytomas, whose brother had a history of a malignant pheochromocytoma, was referred to our institution with symptoms of adrenal crisis including general fatigue and insomnia in spite of increasing predonisolone therapy. Screening by ultrasonogram and computed tomography demonstrated multiple well-demarcated, enhancing nodules (maximum, 3xa0cm) in the head and tail of pancreas and multiple cystic lesions throughout the entire pancreas. Although this patient met the criteria for VHL, magnetic resonance imaging for her brain did not reveal any lesions. Pancreatoduodenectomy with partial distal pancreatectomy was performed. Histologic examination of the resected pancreas revealed multiple well-differentiated endocrine neoplasms accompanied with multiple serous cysts. The patient remains free of disease 5xa0years after surgery.