Hironobu Onishi

Long-Term Prognosis After Treatment of Patients with Choledocholithiasis

Objective This study was conducted to examine the long-term prognosis of after treatment of patients with choledocholithiasis, including the recurrence of lithiasis, and to thereby determine the best treatment modality for choledocholithiasis based on its pathological entity. Summary Background Data Choledocholithiasis can be caused by either primary bile duct stones that originate in the bile duct or by secondary bile duct stones that have fallen out of the gallbladder. The recurrence rates vary depending on the type of choledocholithiasis. Methods Two-hundred thirteen outpatients who were treated for choledocholithiasis from 1982 to 1996 were selected as subjects and monitored for a period ranging from 5 to 19 years (mean, 9.6 years). The 213 patients were divided into 3 groups: 87 patients who had undergone choledocholithotomy and T-tube drainage (including the use of the laparoscopic method), 44 patients who had undergone choledochoduodenostomy, and 82 patients whose stones were removed by endoscopic sphincterotomy (EST). Recurrence of lithiasis was examined for each type of treatment modality. Results Choledochoduodenostomy was performed in 44 cases for the purpose of preventing any recurrence. The recurrent rate was analyzed in 169 cases. Choledocholithiasis recurred in 17 of the 169 cases (10.1%). The remaining 152 patients that showed no recurrence of lithiasis were examined and compared. The diameter of the common bile duct measured during the initial treatment was more dilated in patients with recurrent lithiasis (16.6 ± 5.9 mm) than in patients without any recurrence (9.8 ± 4.9 mm; P < 0.05). Peripapillary diverticula were observed in 10 of the 17 patients with recurrent lithiasis (58.8%), and in 34 of the 152 nonrecurrent patients (22.3%), showing that diverticula were more common in recurrent cases (P < 0.05). Furthermore, while primary bile duct stones were found in 11 of the 17 cases with recurrent lithiasis (64.7%), primary stones were found in only 37 of the 152 nonrecurrent patients (24.3%), showing primary bile duct stones were also more common in recurrent patients (P < 0.05). The recurrent patients were examined by surgical procedure. Nine patients with choledocholithotomy and T-tube drainage had a recurrence (10.3%), and 8 patients in the EST group had a recurrence (9.8%). The recurrence rates for these procedures were higher than for cases with choledochoduodenostomy (recurrence rate: 0%, P < 0.05). In particular, lithiasis recurred in 5 of the 12 patients with T-tube drainage for primary bile duct stones (41.7%). Conclusion Although choledocholithotomy and T-tube drainage, including open and laparoscopic surgery, is presently a common procedure for choledocholithiasis, this procedure will not necessarily prevent a recurrence of the disease. For older patients with primary bile duct stones, choledochoduodenostomy or EST is recommended.

The evaluation of duct-to-mucosal pancreaticojejunostomy in pancreaticoduodenectomy

This study was conducted to examine the efficacy of duct-to-mucosal pancreaticojejunostomy compared with external stented pancreaticojejunostomy in prevention of several complications, retrospectively. Seventy-six patients with pancreatic head resection (59 male; median age, 60.1 years) underwent pancreaticoduodenectomy at the Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan, between January 1, 1994, and March 31, 2002. In early postoperative status, the incidence of pancreatic fistula by duct-to-mucosal anastomosis (n = 45) was similar to that by external stent (n = 31); soft pancreas is a risk factor of pancreatic fistula compared with hard pancreas (p < 0.05). During the late postoperative period, however, no patients with duct-to-mucosal anastomosis showed pancreatic duct dilatation by computed tomography (CT). At the same time, 58.8% of patients with external stent followed by CT showed pancreatic duct dilatation (p < 0.01). The duct-to-mucosal anastomosis was more effective pancreaticojejunostomy than the external stent in terms of prevention of pancreatic duct dilatation, and it should be the surgical procedure of choice in pancreaticoduodenectomy.

Effectiveness of the clinical pathway to decrease length of stay and cost for laparoscopic surgery

AbstractsBackground: Although clinical pathways have become popular strategies to improve the quality of medication in the field of laparoscopic surgeries, their economical effectiveness is not well defined. The aim of this study was to investigate the effect of clinical pathways for laparoscopic surgeries on cost and length of hospital stay. Methods: From January 2000 to June 2001, clinical pathways were introduced for laparoscopic surgeries, such as laparoscopic cholecystectomy (Lap. C, n = 210), laparoscopically assisted distal gastrectomy with Billroth-I reconstruction (Lap. B-I, n=33), and laparoscopically assisted colectomy (Lap. colon, n=34). We compared total lengths of hospital stay and the economical efficiency before and after pathway implementation at Wakayama Medical University Hospital. Results: The length of hospital stay in Lap. C was shortened from 7.8±2.6 (mean±SD) days to 6.9±2.0 days (p = 0.03) and the total costs during hospitalization decreased from ¥509,320±58,800 to ¥489,130±43,860 (p=0.009), resulting in less burden for patients. At the same time, the daily costs were increased from ¥66,230±8920 to ¥70,840±6820 (p=0.0001), indicating that more efficient medical care was being given to patients. Similar results were obtained in Lap. B-I and Lap. colon groups. Conclusions: In our study, the implementation of clinical pathways in the field of laparoscopic surgeries produced significant decreases in length of total hospital stay and cost while maintaining the quality of patient outcomes.

Locoregional chemotherapy for patients with pancreatic cancer intra-arterial adjuvant chemotherapy after pancreatectomy with portal vein resection.

Introduction and Aims The survival of pancreatic cancer patients with portal vein resection is extremely poor due to the high incidence of liver metastasis. The occurrence of liver metastasis is decreased by locoregional arterial infusion after pancreatic surgery. Chemosensitivity tests can provide the basis for individualized chemotherapy in each patient and predict the clinical response. Therefore, the current study was designed to clarify whether locoregional chemotherapy based on the results of chemosensitivity tests has the clinical effects of preventing liver metastasis and improving survival for patients with portal vein resection. Methodology The resected specimens from 40 of 47 patients with resection of pancreatic cancer were assessed for chemosensitivity to various anticancer drugs. Fourteen patients underwent portal vein resection due to direct invasion, and nine of these patients received intra-arterial adjuvant chemotherapy on the basis of the results of MTT assay to prevent liver metastasis. The remaining five patients received no chemotherapy. Results None of the patients who received intra-arterial chemotherapy had liver metastasis, and this group of patients had improved survival. The mean survival of patients with intra-arterial chemotherapy was significantly longer than that of patients without chemotherapy (25.6 months with chemotherapy versus 9.4 months without chemotherapy). Conclusion A pilot study of postoperative intra-arterial chemotherapy showed the reduction of liver metastasis and improvement of survival among pancreatic cancer patients with portal vein resection.

Adenosquamous Carcinoma of the Pancreas: Successful Treatment with Extended Radical Surgery, Intraoperative Radiation Therapy, and Locoregional Chemotherapy.

SummaryBackground. Adenosquamous carcinoma of the pancreas is a rare tumor with an extremely poor survival rate. No obvious evidence that multidisciplinary treatments improves the prognosis and survival has been reported. Patient and Results. A 63-yr-old female with adenosquamous carcinoma of the pancreas underwent extended radical surgery, intraoperative radiation therapy, postoperative intraarterial chemotherapy, and external beam radiation therapy. The patient is alive at 40 mo after surgery with no recurrence. Conclusions. Multidisciplinary treatments including aggressive surgery, intraoperative radiation therapy, and locoregional chemotherapy might improve the survival of patients with adenosquamous carcinoma of the pancreas to inhibit liver metastasis and local recurrence.

Solid and cystic tumor of the pancreas

SummaryBackground. Solid and cystic tumor (SCT) of the pancreas can be distinguished from other pancreatic neoplasms by its nearly exclusive occurrence in young women, and its favorable prognosis after complete resection.Methods. We experienced four cases with SCT of the pancreas, and analyzed these tumors by immuno-histochemical and electron microscopic studies, as well as genetic analysis of ras oncogene mutation.Results. The presented cases expressed the neuron-specific enolase in two cases, α1-antitrypsin and α1-antichymotrypsin in two cases, and vimentin in one case, which indicated that this tumor originates from pleuripotential embryonic stem cells. No patients had mutations of K-ras gene in codon 12, and further genetic analysis is required to predict the malignant potential. Conclusion. SCT of the pancreas appears to have limited malignant potential and the metastatic ratio is not high, although the tumor has local invasion. Therefore, an aggressive surgical approach seems fully justified.

Clinical features of ciliated foregut cyst of the gallbladder: A rare entity of cystic lesion in the gallbladder

A ciliated cyst of foregut origin may arise in relation to the tracheobronchial tree (1), mediastinum (2), liver (3), pancreas (4), tongue (5), and upper digestive tract (6). To our knowledge, only three cases of gallbladder cyst lined by ciliated epithelium have been reported (7–9). Ciliated cysts are considered to be benign, but they are difficult to differentiate from malignant neoplasm preoperatively when radiological studies show a cystic structure in or adjacent to the gallbladder (7). Since magnetic resonance cholangiopancreatography (MRCP) effectively reveals bile duct cyst, liver cyst, and pancreatic cyst (10), we used MRCP for the diagnosis of this rare entity. We report a case of ciliated intramural cyst of the gallbladder and clarify the clinical significance in terms of clinical and pathological features.

Preoperative antimicrobial administration for prevention of postoperative infection in patients with laparoscopic cholecystectomy.

The present study was designed to investigate whether the administration of antimicrobial agents before laparoscopic cholecystectomy (LC) is more effective for prevention of postoperative infection. During the period from January 1991 to September 2001, 397 patients treated with sulbactam/cefoperazone (SBT/CPZ) for prevention of postoperative infection were studied: 200 patients received SBT/CPZ 1 hr before LC, and 197 patients were not given the preoperative treatment. The positive rate of bacteria in the gallbladder bile in the group receiving preoperative SBT/CPZ was 12.0%, a significant suppression compared with 19.8% in the group without preoperative treatment (P < 0.05). Identification of microorganisms in the bile revealed E. coli and Klebsiella in the preoperative treatment group, which showed a significant suppression (P < 0.05). The mean white blood cell count was significantly lower in the preoperative treatment group (9860/μl) than in the nonpreoperative treatment group (10,520/μl) (P < 0.05). The above results demonstrate that administration of SBT/CPZ before LC suppressed the level of bacteria in the bile, resulting in a significant reduction in complications induced by postoperative infection.

THE USEFULLNESS OF THE SCORE CRITERIA FOR DECISION-MAKING OF TREATMENT FOR ACUTE APPENDICITIS

In order to rule out catarrhal appendicitis and to judge only phlegmonous or gangrenous appendicitis as operative candidate, a prospective study applying our designed score criteria comprising of six clinical and laboratory items has been conducted. There were five cases of false positive and 2 cases of false negative, but the judgment according to the criteria was correct in 140 out of 147 subjects, the correct diagnosing rate being as high as 95.2%. It has been demonstrated that the score criteria can be clinically applied. Furthermore, ultrasonography performing for all patients complaining of a right lower abdominal pain would greatly contribute to make the differential diagnosis between acute appendicitis and such diseases mimicking acute appendicitis as colonic diverticulum, mesenteric lymphadenitis, and ureterolith. We believe that unnecessary laparotomy can be avoided for this score criteria.