Isao Kurosaki

Outcome of radical surgery for carcinoma of the gallbladder according to the TNM stage

BACKGROUND The role of surgery in the treatment of gallbladder carcinoma (GBC) is controversial. The outcome after prospective radical surgery for GBC is discussed on the basis of the TNM stage of the tumor. METHODS One hundred six patients who had undergone radical surgery were selected. The standard radical procedure consisted of a cholecystectomy accompanied by lymph node dissection, wedge resection of the liver, and resection of the extrahepatic bile ducts. The stage was determined by pathologic examination of resected specimens. RESULTS Lymph node metastases were identified in no patients with T1 tumors (n = 15), 48% of patients with T2 tumors (n = 46), 72% of patients with T3 tumors (n = 25), and 80% of patients with T4 tumors (n = 20). One patient died within 30 days after radical surgery (mortality rate, 0.9%). There were 35 5-year survivors including 11 patients with nodal involvement, 10 with stage I tumors, 13 with stage II tumors, 10 with stage III tumors, and 2 with stage IV tumors. The cumulative 5-year survival rate in patients with stage I tumors was 91% (n = 15), 85% in patients with stage II tumors (n = 24), 40% in patients with stage III tumors (n = 28), and 19% in patients with stage IV tumors (n = 39). In patients with stage III and IV tumors the 5-year survival rate was 52% after curative resection (n = 35). This was significantly better than the 5% 5-year survival rate after a noncurative resection (n = 32). CONCLUSIONS The presence of lymph node metastases is strongly influenced by the depth of invasion of the primary tumor. Accurate determination of the TNM stage is essential in comparing surgical results, predicting patient outcome, and planning additional treatment. Standard radical surgery contributes to patient survival and is recommended in patients with advanced GBC.

Surgical interventions for focal progression of advanced gastrointestinal stromal tumors during imatinib therapy.

BackgroundAlthough imatinib has shown high activity in the majority of patients with advanced gastrointestinal stromal tumors (GIST), it has become clear that secondary resistance appears during chronic therapy. The aim of this study was to retrospectively analyze the safety and prognostic effects of surgical interventions for focal progression during imatinib treatment.MethodsBetween January 2002 and May 2005, 16 patients who had focal lesions of secondary-resistant GIST to imatinib treatment (male/female, 12 : 4; median age, 62 years) underwent surgical interventions such as resection, radiofrequency ablation, and their combination.ResultsPostoperative complications, including liver abscess, bile leak, wound infection, and ileus were mostly mild, and the patients recovered with conservative therapy. There was no hospital death. The median time to progression (TTP) of all patients was 5.5 months, and only one patient died of the disease; the others are alive after a median follow up of 12.4 months. Patients with complete resections of resistant lesions (n = 7) showed significantly better median TTP than those with incomplete resections (n = 9; P = 0.014). The impact of curability on focal lesions with secondary resistance was mainly significant in patients with tumors of stomach origin (P = 0.013), and a smaller number (P = 0.014) and smaller size (P = 0.018) of resistant lesions. Overall survival was 100% at 1 year and 75% at 2 years.ConclusionOur study indicates that surgical interventions in patients with GIST resistant to imatinib therapy are efficacious when complete resections are performed, when the lesions are of gastric origin, when the number of lesions is lower, and when the lesions are a smaller size.

Left Posterior Approach to the Superior Mesenteric Vascular Pedicle in Pancreaticoduodenectomy for Cancer of the Pancreatic Head

CONTEXT Dissection of the superior mesenteric artery is the most important part of a pancreaticoduodenectomy for pancreatic cancer. Since 2005, we have used the left posterior approach for superior mesenteric vascular pedicle dissection, in which the superior mesenteric artery and the superior mesenteric vein are dissected first in a clockwise fashion. OBJECTIVE This article presents the technique of a left posterior approach and the clinical outcome. PATIENTS Forty patients underwent a left posterior approach and were compared to 35 patients treated with a conventional dissection. MAIN OUTCOME MEASURES The differences in surgical technique between the left posterior approach and the conventional method were described, and the short- and long-term surgical results compared patients who underwent the left posterior approach to those who were treated with the conventional method. INTERVENTION The superior mesenteric vascular pedicle was first dissected from the left lateral border of the superior mesenteric artery. The superior mesenteric vein was also dissected from the left side. Then, the uncinate process and perivascular soft tissue were separated en bloc from the vasculature. RESULTS No life-threatening complications occurred after the pancreaticoduodenectomies using a left posterior approach. Diarrhea requiring the administration of antidiarrheal agents occurred in 65% of patients; however, planned adjuvant chemotherapy was completed in all patients who did not have an early tumor recurrence. Survival rate was 52.8% at 3 years after surgery. CONCLUSION After a pancreaticoduodenectomy with a left posterior approach, most patients had various degrees of diarrhea, but the adjuvant chemotherapy was able to be continued with close monitoring. The left posterior approach facilitates understanding of the topographic anatomy in the superior mesenteric vascular pedicle.

The mode of lymphatic spread in carcinoma of the bile duct

BACKGROUND Knowing the prevalence of lymph node involvement associated with the location of the primary tumor is a prerequisite for operating with curative intent in carcinoma of the bile duct. METHODS We evaluated 80 patients with carcinoma of the bile duct or cystic duct to investigate the frequency of lymph node involvement, the mode of lymphatic spread, and prognosis, according to the location of the primary tumor. RESULTS The frequency of lymphatic spread of carcinomas in the proximal, middle, and distal bile ducts, excluding seven T1 tumors, was 48%, 67%, and 56%, respectively. With regard to the mode of lymphatic spread: (1) a metastatic pathway along the common hepatic artery predominated over that to the retropancreatic area in the proximal duct carcinoma group; (2) in the middle duct carcinoma group, metastatic lymph nodes were distributed widely, involving nodes around the superior mesenteric artery or at the para-aortic area; and (3) in the distal duct carcinoma group, metastatic nodes generally were localized around the head of the pancreas. CONCLUSIONS Understanding the mode of the lymphatic spread according to the primary tumor may be helpful for choosing the appropriate surgical approach with curative intent in bile duct carcinoma.

Preservation of the left gastric vein in delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy.

The definition of delayed gastric emptying (DGE) after pyloric-preserving pancreaticoduodenectomy (PPPD) varies among surgeons. We compared and evaluated three different definitions reported elsewhere. In addition, we investigated the correlation between multiple surgical factors and recovery of gastric motility. First, 55 consecutive patients were reviewed to assess the three different definitions. Second, surgical factors affecting gastric motility were investigated in 46 patients showing no major complications. All 55 patients underwent PPPD, which was reconstructed with antecolic duodenojejunostomy, with aggressive lymph node dissection and with no mortality. The duration of nasogastric intubation was 2 days, and a solid diet started on the 12th postoperative day (median). Re-nasogastric intubation or emesis was observed in 12.7% of patients. Overall, DGE occurrence rate was 5.5%-29.1%, with striking differences depending on the type of definition. Technically, division of the left gastric vein was accompanied with significantly delayed removal of the nasogastric tube (3 versus 2 days, P = 0.0002) and delayed start on a solid diet (14 versus 9 days, P <0.0001) compared with its preservation. Antecolic duodenojejunostomy after PPPD improved DGE occurrence despite aggressive surgery, and preservation of LGV accelerated restoration of gastric motility in our experiments. However, an understanding of a common definition of DGE is needed when discussing the outcome of the various interventions.

Portal Vein Resection in Surgery for Cancer of Biliary Tract and Pancreas: Special Reference to the Relationship Between the Surgical Outcome and Site of Primary Tumor

BackgroundEarly and late outcomes after superior mesenteric-portal vein resection (VR) combined with pancreaticoduodenectomy, major hepatectomy, or both for pancreaticobiliary carcinoma were retrospectively evaluated. VR is the most frequently used vascular procedure in this field, but an exact role of VR has not been compared according to the primary site of tumor.Materials and MethodsPostoperative outcomes were compared between surgery with and without VR in each of the three disease-based groups: hilar cholangiocarcinoma and intrahepatic cholangiocarcinoma with hilar extension (HIC, 56), middle and distal cholangiocarcinoma and gallbladder carcinoma (DGC, 118), and pancreatic head adenocarcinoma (PHC, 77).ResultsVR was performed in 19.6% of HIC, 8.5% of DGC, and 45.5% of PHC. In-hospital death was 7.1% (4 of 56) patients with VR (3 of DGC and 1 of PHC). Operations with VR in DGC showed a larger amount of blood loss and more increased ratio of R1operation than those with no VR. In HIC, DGC, and PHC, median survival time of patients with VR was 37, 6.8, and 20 months and that of patients without VR was 42.9, 28.6, and 20.3 months, respectively. VR did not affect survival either in HIC or in PHC; however, in DGC, VR was accompanied with dismal outcome compared with no VR (p = 0.001).ConclusionsAggressive surgery with VR can be justified both in HIC and in PHC but should not be recommended for DGC. Surgical outcomes of VR differed considerably, depending on the sites of the primary tumor.

Intrahepatic cholangiocarcinoma arising 34 years after excision of a type IV-A congenital choledochal cyst: Report of a case

We report a rare case of intrahepatic cholangiocarcinoma (IHCC) arising many years after excision of a type IV-A congenital choledochal cyst. A 44-year-old man was transferred to our hospital with acute cholangitis more than 34 years after several operations for congenital biliary dilatation. Imaging showed a huge tumor in the left medial section of the liver, extending to the porta hepatis. Although he had no jaundice, the intrahepatic bile ducts showed cylinder-like dilatation with narrowing of the hilar bile duct. At surgery, the tumor was found to arise from the dilated intrahepatic bile duct just above the narrow portion. He underwent a left hepatic trisectionectomy with a vascular procedure. Microscopically, the tumor was confirmed to be moderate-to-well-differentiated tubular adenocarcinoma. Thus, when the narrow segment is left untouched, careful long-term follow-up is important to detect new lesions at an early stage.

A pharmacological analysis of prostaglandin E1 on portal blood flow after partial hepatectomy in rats.

Portal venous flow (PVF) and portal venous pressure (PVP) were examined after the jugular or portal injection of Prostaglandin E1 (PGE) in rats partially hepatectomized by either 40% or 66%. In the 66% hepatectomized animals, the jugular injection of PGE at 5.0 μg/kg/min produced an increase in PVF concomitant with a fall in systemic arterial pressure (SAP), while PVP remained unchanged. The portal injection of PGE at 0.5 μg/kg/min increased PVF to a level equivalent to that evoked by the jugular injection of 5.0 μg/kg/min PGE, without any change in SAP. PVP was reduced synchronistically with an increase in PVF. The PVF response to a portal injection of PGE at 0.5 μg/kg/min was not reproduced in liver intact rats. These results suggest that PGE is potent in increasing PVF in the partially resected condition of the liver and that the portal vascular bed is involved in this response.

Liver perfusion chemotherapy with 5-Fluorouracil followed by systemic gemcitabine administration for resected pancreatic cancer: preliminary results of a prospective phase 2 study.

Objectives: Liver perfusion chemotherapy (LPC) for pancreatic cancer has been rarely undertaken in a postoperative adjuvant setting. We evaluated the feasibility and antitumor efficacy of LPC with 5-fluorouracil (5-FU) followed by gemcitabine treatment. Methods: This prospective study enrolled 27 patients who underwent pancreatic resection and subsequent LPC + gemcitabine treatment during a 3-year period. The liver was infused with 5-FU (125 mg/body per day per route) via both routes of hepatic artery and portal vein for more than 21 days. After that, gemcitabine (1000 mg/m2) was administered biweekly. Results: Portal vein thrombosis developed in 1 patient, but 89% patients tolerated LPC for more than 21 days with no life-threatening complication. Systemic administration of gemcitabine was accomplished in 93%; however, 1 patient died of serious capillary leak syndrome. No grade 4 toxicity was recorded, except for that patient. Median survival time and disease-free survival were 27.5 and 24.5 months, respectively. Hepatic relapse was observed in 25.9% (n = 7). Survival was in favor of paraaortic node-negative cases (n = 20) with a 2-year survival of 68.7%. Conclusions: Liver perfusion chemotherapy was feasible with acceptable toxicity. Systemic use of gemcitabine also seems to be safe for the most part. This adjuvant chemotherapy shows promising survival benefit and seems to be indicative to paraaortic node-negative tumors.

Successful resection of metachronous liver metastasis from α-fetoprotein-producing gastric cancer: Report of a case

We present herein the case of a 68-year-old man in whom metachronous liver metastasis from an α-fetoprotein (AFP)-producing gastric cancer was successfully treated. The patient initially underwent a distal gastrectomy for an AFPproducing gastric cancer on January 30, 1997, following which the serum AFP level which had been 228 ng/ml prior to surgery decreased to 30 ng/ml. However, 7 months after surgery, follow-up examination revealed an abnormal elevation of the serum AFP level up to 301 ng/ml, and a liver tumor was subsequently detected at segment 8 (S8) by abdominal ultrasonography. There was no evidence of hepatitis B or C virus infections. After various investigations, he was diagnosed to have liver metastases in S6 and S8, from the AFP-producing gastric cancer, and a partial hepatectomy of S6 and S8 was performed. His postoperative course was uneventful and he was discharged on postoperative day 26. Thereafter, his serum AFP levels decreased and have remained within normal limits for 12 months since his operation. To the best of our knowledge, this is the first case of successful resection of metachronous liver metastasis from an AFP-producing gastric cancer.