Ichirou Konishi

Clinicopathological study of pancreatic carcinoma with particular reference to the invasion of the extrapancreatic neural plexus.

SummaryA clinicopathological study of 44 ductal carcinomas of the head of the pancreas revealed 39 with retroperitoneal invasion, of which 27 showed extrapancreatic plexus involvements. The second portion of the plexus pancreaticus capitalis was the most frequent site of invasion. A statistically significant correlation was found between neural invasion in the pancreatic tissue and plexus invasion, but no clear correlation was found between plexus invasion and lymphatic invasion or tumor size. Even small-sized tumors (t1) showed plexus invasion. The cases with plexus invasion had a statistically higher incidence of lymph-node involvement around the superior mesenteric artery than those without plexus invasion.These results indicate that complete dissection of extrapancreatic plexus around the superior mesenteric artery, including lymph nodes and soft tissue, could prolong the survival of patients with ductal carcinoma of the pancreas, even in cases of small-sized carcinomas.

The results and problems of extensive radical surgery for carcinoma of the head of the pancreas.

Since 1973, 152 patients with pancreatic carcinoma have undergone surgery in our clinic, including 110 with carcinoma of the head of the pancreas. Of these 110 patients, resections were performed on 43 (39.1 per cent), 33 (30 per cent) of whom underwent a curative resection based on macroscopic evidence. Six of the patients who underwent macroscopic curative resection survived for five years, giving a five-year survival rate of 36.5 per cent by the Kaplan-Meier method after excepting 6 operative deaths. We compared the extent of pancreatic cancer by constructing survival curves according to the General Rules published by the Japan Pancreas Society. There was no statistical difference in survival based on tumor size or stage, however, there was a significant difference in the survival curves of so and se, being the absence or presence of the anterior capsule of the pancreas, rpo and rpe, being the absence or presence of invasion of the retroperitoneal tissue; ew(−) and ew(+) being the absence or presence of invasion at the surgical margin of resection, or n0 and n1 being the extent of lymph node metastasis. The results of this comparison suggest that extended radical pancreatectomy may be indicated for the treatment of pancreatic cancer as the standard radical operation for pancreatic cancer may miss tumors which have spread to the retroperitoneum and extrapancreatic nerve plexus.

The pattern of lymph node involvement in carcinoma of the head of the pancreas. A histologic study of the surgical findings in patients undergoing extensive nodal dissections.

SummaryTo clarify the pattern of lymph node metastasis in carcinoma of the pancreas, lymph node involvement was examined in forty-two patients who underwent extensive nodal dissections, including the paraaortic lymph nodes. The correlation between the spread of the tumor and lymph node involvement was evaluated: The most common site of involved lymph nodes was the retropancreatic region. The prevalence of nodal metastases was 78.6%. Metastases to the paraaortic region were present in seven patients, among whom metastases in the paraaortic region were most common in the median region from the celiac artery to the inferior mesenteric artery and in the space between the aorta and the vena cava. The risk of lymph node metastases tended to increase with tumor size, except in the paraaortic region, where the correlation between the frequency of metastasis and tumor size was poor. The probability of lymph node metastases increased with the degree of lymphatic invasion (ly) and the growth pattern of the tumor (INF) and was high in patients with invasion into the retropancreatic tissue and in tumors with scirrhous histology. These results indicate that even in small cancers, lymph nodes of the paraaortic region frequently harbor metastases and should be dissected en block during radical resections of pancreatic cancer.

Surgical treatment of pancreatic cancer

SummarySince 1973, 194 patients with pancreatic carcinoma have undergone surgery in our clinic, including 134 with carcinoma of the head of the pancreas. Of these 134 patients, resections were performed on 61 (45.5%), 49 (36.6%) of whom underwent a curative resection based on macroscopic evidence. Seven of the patients who underwent macroscopic curative resection sur vived for five years, giving a five-year survival rate of 26.4% by the Kap lan-Meier method after excepting seven operative deaths. We compared the extent of pancreatic cancer by constructing survival curves according to the General Rules published by the Japan Pancreas Society. There was no statistical difference in survival based on tumor size or stage; however, there was a significant difference in the survival curves of so and se, being the absence or presence of the anterior capsule of the pancreas; rpo and rpe, being the absence or presence of invasion of the retroperitoneal tissue; ew( -) and ew( +), being the absence or presence of invasion at the surgical margin of resection; and no and n1, being the extent of lymph node meta stasis. The results of this comparison suggest that extended radical pan createctomy may be indicated for the treatment of pancreatic cancer, since the standard radical operation for pancreatic cancer may miss tumors that have spread to the retroperitoneum and extrapancreatic nerve plexus.

Recurrence of intrahepatic stones after an end-to-side choledochojejunostomy

The risk factors for the recurrence of intrahepatic stones after an end-to-side choledochojejunostomy were investigated, along with the outcome following the treatment of such stones. Thirty-two patients with intrahepatic stones underwent an end-to-side choledochojejunostomy, and a complete lithotomy was achieved in 26 of them. The follow-up which ranged from 5-19 years after surgery revealed that eight patients developed a recurrence of intrahepatic stones, and their clinical and cholangiographic findings were thus reviewed. Recurrent stones were associated with onset of symptoms at a younger age and were predominantly located in the intrahepatic bile ducts. Recurrence was also associated with severe intrahepatic bile duct dilatation. Six of the eight patients developed recurrent stones more than 5 years after a complete lithotomy. One of these patients died of liver cirrhosis while two died of acute obstructive suppurative cholangitis. Five patients underwent cholangioscopic lithotomy through the jejunostomy for their recurrent stones, and a complete lithotomy was accomplished in three of them. These findings indicate the necessity of performing a hepatectomy in such patients whenever possible, and also emphasize the need for a long-term follow-up after a complete lithotomy with an end-to-side choledochojejunostomy. In addition, any recurrent stones should be treated promptly by a cholangioscopic lithotomy through a jejunostomy.