Hisao Kano

Preventing delayed gastric emptying in pancreaticogastrostomy by a modified subtotal-stomach-preserving pancreaticoduodenectomy: Oida modification.

BACKGROUND/AIMS Delayed gastric emptying (DGE) is one of the most troublesome complications of pylorus-preserving pancreaticoduodenectomy (PPPD). In Japan, since the 1990s, subtotalstomach- preserving pancreaticoduodenectomy (SSPPD) has been performed as an alternative to PPPD. Here, we evaluated the efficacy of our modification of the original SSPPD technique as compared to PPPD with an aim to decrease the incidence of DGE. METHODOLOGY We retrospectively analyzed 67 patients who underwent PD with pancreaticogastrostomy (PG). They were divided into 2 groups on their basis of the surgical treatment: the PPPD group and the modified SSPPPD (MSSPPD) group. The incidence of DGE was determined and compared between the 2 groups. RESULTS In the MSSPPD group, 98%, 2%, and 0% of the cases developed class A, class B, and class C DGE, respectively; the corresponding values in the PPPD group were 4%, 52%, and 44%, respectively. The incidence of DGE differed significantly between the 2 groups (p<0.0001). CONCLUSIONS We consider that our reconstruction procedure is useful for preventing DGE in patients who have undergone SSPPD with PG.

Protection of major vessels and pancreaticogastrostomy using the falciform ligament and greater omentum for preventing pancreatic fistula in soft pancreatic texture after pancreaticoduodenectomy.

BACKGROUND/AIMS Pancreatic fistula is one of the major causes of morbidity in patients undergoing pancreaticoduodenectomy. Protection of the skeletonized vessels and the anastomotic site of pancreaticoenterostomy is one of the surgical options to prevent the development of a pancreatic fistula. The aim of this study was to describe an operative technique to protect the vessels and anastomotic site by wrapping them with the falciform ligament and the greater omentum. METHODOLOGY After a modified subtotal stomach-preserving pancreaticoduodenectomy reconstruction with pancreaticogastrostomy was performed, the falciform ligament and greater omentum was used on the skeletonized major vessels and wrapped around the anastomotic site of pancreaticogastrostomy. Twenty consecutive patients were enrolled in this prospective study. RESULTS The entire procedure did not result in any operative complications. Postoperative pancreatic fistula developed in 2 cases (10%). According to the international postoperative pancreatic fistula criteria, grade A and grade B was observed in 1 case each. No intra-abdominal hemorrhage and late intra-abdominal abscess were observed. CONCLUSIONS This procedure is a convenient and safe technique, and may be helpful in preventing major complications caused by pancreatic fistula.

Long-term survival after resection of mass-forming type intrahepatic cholangiocarcinoma directly infiltrating the transverse colon and sequential brain metastasis: Report of a case.

MUC1 expression in cholangiocarcinoma is considered to be correlated with patient survival. We report a case of mass-forming type intrahepatic cholangiocarcinoma (ICC) with direct infiltration of the transverse colon and sequential brain metastasis. The patient was treated by curative right hepatectomy with right hemicolectomy followed by resection of the brain metastasis; there has been no evidence of recurrence in the 7 years since the hepatic resection. Thus, surgical resection may improve the prognosis of ICC involving the adjacent organs, even with brain metastasis. Immunohistochemical staining was performed for MUC1, MUC2, and MUC5AC. Although MUC1 expression was found in the liver tumor and metastatic brain tumor, the correlation between MUC1 expression and the prognosis of this patient was unclear. To clarify the correlation between immunohistochemical characteristics and prognosis, further studies on a greater number of cases of long-term survival of mass-forming type ICC are needed.

Gastric marginal ulcer after pancreaticoduodenectomy with pancreaticogastrostomy due to delayed gastric emptying and Helicobacter pylori infection.

BACKGROUND/AIMS Marginal ulceration and delayed gastric emptying are considerable problems after pancreaticoduodenectomy. Helicobacter pylori (HP) are well known to be associated with gastritis, gastric ulcer and gastric cancer. Thus, we studied the relationship between marginal ulceration and delayed gastric emptying in the early postoperative period after pancreaticoduodenectomy with pancreaticogastrostomy. METHODOLOGY We retrospectively studied 58 patients who underwent pancreaticoduodenectomy with pancreaticogastrostomy. On the basis of the grade of delayed gastric emptying, these patients were divided into 2 groups-WS group; without/with slight delayed gastric emptying and MS group; moderate/severe delayed gastric emptying. RESULTS Two patients (3.4%) developed postoperative marginal ulcer, these 2 patients had no HP infection; moreover, they belonged to the MS group. Five patients in the WS group were infected with HP; although, postoperative marginal ulceration did not develop in these 5 patients. CONCLUSIONS Delayed gastric emptying might be a stronger promoting factor of postoperative marginal ulcer after pancreaticoduodenectomy with pancreaticogastrostomy rather than HP infection and prevention of delayed gastric emptying is important to reduce the occurrence rate of postoperative marginal ulcer. Our modified subtotal stomach-preserving pancreaticoduodenectomy is a useful procedure for preventing delayed gastric emptying and postoperative marginal ulcer after pancreaticoduodenectomy with pancreaticogastrostomy.

Diffuse Peritonitis due to Perforated Gastric Ectopic Pancreas.

Ectopic pancreas is frequently found in the gastrointestinal tract. Lesions comprise well-developed and normally organized pancreatic tissue outside the pancreas, without anatomic or vascular connections with the true pancreas. Most patients with ectopic pancreas are asymptomatic or exhibit nonspecific symptoms. A 68-year-old Japanese woman had been experiencing intermittent pain in the right upper abdomen. Suddenly, the abdominal pain changed to intense pain in the right flank of the abdomen 2 days later. On initial medical examination, the abdomen exhibited rebound tenderness and distension. The results of laboratory tests revealed increased inflammatory reaction. Abdominal computed tomography showed free air and ascites on the surface of the liver and elevated levels of adipose tissue around the antrum and pylorus of the stomach. Perforation of the upper gastrointestinal tract was diagnosed and we performed urgent surgery. The site of perforation, whose size was 25 mm, was the lesser curvature of the antrum of the stomach. Since it was not possible to perform omentopexy, we performed extensive gastric resection. The reconstruction was a Billroth II operation. Microscopic analysis revealed pancreatic tissue within the ulceration, showing islets of Langerhans, acini, and ducts; the lesion was diagnosed as type I using Heinrich’s criteria. The postoperative course was uneventful. The patient was discharged on day 13 and remains clinically healthy. Gastric perforation due to ectopic pancreas has been reported in 2 cases, including our patient, and is extremely rare. Once gastric perforation has been diagnosed, the presence of ectopic pancreas might be considered.

Killian-Jamieson Diverticula Presenting Synchronously with Thyroid Adenoma

Killian-Jamieson diverticulum is a rare hypopharyngeal diverticulum, less commonly encountered compared with Zenkers diverticulum. These hypopharyngeal diverticula that cause dysphagia often mimic a thyroid tumor incidentally detected on neck ultrasonography. However, to our knowledge, Killian-Jamieson diverticula complicated by a thyroid tumor have not been previously described. We experienced a rare case of bilateral Killian-Jamieson diverticula synchronously complicated by a thyroid adenoma in a 74-year-old woman who became aware of dysphagia and a tumor in the left side of her neck. Pharyngoesophagography revealed bilateral diverticula protruding from the lateral wall of the esophagopharyngeal junction, but the appearance of the cricopharyngeal bar representing the cricopharyngeus muscle above the diverticula had become unclear because the thyroid tumor was pressing on the diverticula and the cervical esophagus. However, the diverticula were diagnosed as Killian-Jamieson diverticula because cervical computed tomography showed bilateral diverticula arising from the cervical esophagus just below the level of the cricoid cartilage, and operative finding showed that the diverticula were located above the upper esophageal longitudinal muscle. Radiographic imaging is useful for diagnosis as cause of dysphagia and cervical tumor.

Hand-assisted laparoscopic hepatectomy for primary clear cell hepatocellular carcinoma of the liver.

We report a case of primary clear cell hepatocellular carcinoma of the liver (PCCCL) for which we performed hand-assisted laparoscopic hepatectomy. A 71-year-old female with hepatitis C infection and diabetes mellitus was admitted to our department for a hepatic tumor with gallstone. Abdominal computed tomography revealed a tumor 25 mm in diameter on the surface in segment 5 of the liver. The imaging results suggested small hepatocellular carcinoma located on the surface in segment 5 of the liver, and we performed laparoscopic surgery aiming at a minimally invasive procedure. We performed laparoscopic cholecystectomy and hand-assisted laparoscopic hepatectomy. Histopathological findings showed moderately differentiated hepatocellular carcinoma, and as the proportion of clear cells was 75%, the tumor was diagnosed as PCCCL. This is the first report of hand-assisted laparoscopic hepatectomy for PCCCL. Laparoscopic hepatectomy is a useful minimally invasive surgical procedure when the tumor is located on the surface of the liver.

Jejunal scarf-covering method in pancreaticojejunostomy after total gastrectomy.

Pancreatic fistula is the most serious postoperative complication after pancreaticoduodenectomy, and it leads to intra-abdominal abscess, sepsis, hemorrhage and high mortality. To prevent pancreatic fistula, wrapping of skeletonized vessels and the anastomotic site of the pancreaticoenterostomy using the round ligament, greater omentum, or both has been evaluated. However, the round ligament and greater omentum have already been resected in patients who have previously undergone total gastrectomy, making them unavailable in pancreaticoduodenectomy. Therefore, we developed a procedure for wrapping the anastomotic site of the pancreaticojejunostomy using the jejunum, namely the ‘jejunal scarf-covering method’ as a novel technique to prevent pancreatic fistula following pancreaticoduodenectomy in patients who have previously undergone total gastrectomy.

Promoter hypomethylation of RAR-related orphan receptor α 1 is correlated with unfavorable clinicopathological features in patients with colorectal cancer

Retinoic acid receptor-related orphan receptor α (RORA) is a tumor-specific differentially methylated region. RORA mRNA expression is frequently downregulated in colorectal cancer (CRC) due to promoter methylation, and this methylation is correlated with the development of CRC. Here we investigated the correlation between the methylation status of the RORA promoter region and clinical CRC stages. The methylation status of RORA isoform 1 (RORA1) and isoform 4 (RORA4) promoters was investigated in 43 paired CRC specimens and adjacent normal tissues by quantitative DNA methylation analysis using the Sequenom MassARRAY system and bisulfite sequencing. The relationship between the methylation status of the RORA1 promoter and the CRC pathological stage was analyzed. RORA1 expression was evaluated using quantitative PCR. Sixteen of 43 CRC specimens (37%) and three CRC cell lines (Caco2, HT29, and HCT116) showed increased levels of methylation in the RORA1 promoter region compared with adjacent normal tissues, whereas no methylation was observed in the RORA4 promoter. Quantitative PCR showed downregulation of RORA1 expression both in CRC samples and cell lines. Furthermore, the RORA1 promoter hypomethylation status showed a significant correlation with unfavorable CRC stages (stages III and IV) compared with favorable stages (stages I and II, p = 0.014). Hypomethylation of the RORA1 promoter may have important clinical implications in unfavorable CRC development, and therefore, the methylation status of the RORA1 promoter may constitute a useful biomarker to determine an indication for postoperative therapy such as adjuvant chemotherapy in highly advanced CRC patients.

Gastric Cancer Arising from an Upside-Down Stomach through a Paraesophageal Hiatal Hernia

We report the rare case of an elderly patient with an advanced gastric cancer arising from an upside-down stomach through a paraesophageal hiatal hernia (PEH). An 82-year-old man presented with appetite loss and anemia. Upper gastrointestinal endoscopy revealed a type 1 tumor located in the middle body of the stomach. An upper gastrointestinal series and computed tomography showed organoaxial rotation of the stomach, which was located in the mediastinum, through a PEH, indicating an upside-down stomach. The preoperative diagnosis was gastric cancer arising from an upside-down stomach through a PEH. The patient underwent total gastrectomy with lymph node dissection and closure of the hernial orifice. Although a large PEH is a chronic disorder, gastric malignancies should be considered in patients with PEH manifested as an upside-down stomach due to its anatomical characteristics, and careful preoperative diagnosis is mandatory.