Kenichiro Kato

Management of postoperative arterial hemorrhage after pancreato-biliary surgery according to the site of bleeding: re-laparotomy or interventional radiology

BACKGROUND/PURPOSE Intra-abdominal arterial hemorrhage is still one of the most serious complications after pancreato-biliary surgery. We retrospectively analyzed our experiences with 15 patients in order to establish a therapeutic strategy for postoperative arterial hemorrhage following pancreato-biliary surgery. METHODS Between August 1981 and November 2007, 15 patients developed massive intra-abdominal arterial bleeding after pancreato-biliary surgery. The initial surgery of these 15 patients were pylorus-preserving pancreatoduodenectomy (PPPD) (7 patients), hemihepatectomy and caudate lobectomy with extrahepatic bile duct resection or PPPD (4 patients), Whipples pancreatoduodenectomy (PD) (3 patients), and total pancreatectomy (1 patient). Twelve patients were managed by transcatheter arterial embolization and three patients underwent re-laparotomy. RESULTS Patients were divided into two groups according to the site of bleeding: SMA group, superior mesenteric artery (4 patients); HA group, stump of gastroduodenal artery, right hepatic artery, common hepatic artery, or proper hepatic artery (11 patients). In the SMA group, re-laparotomy and coil embolization for pseudoaneurysm were performed in three and one patients, respectively, but none of the patients survived. In the HA group, all 11 patients were managed by transcatheter arterial embolization. None of four patients who had major hepatectomy with extrahepatic bile duct resection survived. Six of seven patients (85.7%) who had pancreatectomy survived, although hepatic infarction occurred in four. CONCLUSIONS Management of postoperative arterial hemorrhage after pancreato-biliary surgery should be done according to the site of bleeding and the initial operative procedure. Careful consideration is required for indication of interventional radiology for bleeding from SMA after pancreatectomy and hepatic artery after major hepatectomy with bilioenteric anastomosis.

New prognostic factor influencing long-term survival of patients with advanced gallbladder carcinoma

BACKGROUND Although the safety of operations has generally improved in recent years, the mortality of extended operations for advanced gallbladder carcinoma (GBC) remains high, and the outcomes of patients with advanced GBC requiring major surgery are poor. In this study, a newly formulated original stage classification of advanced GBC was evaluated to clarify prognostic factors affecting long-term survival. METHODS A total of 149 patients with resected GBC infiltrating beyond the propria muscle layer were analyzed retrospectively. These patients were classified into F0 (n = 50), F1 (n = 38), F2 (n = 38), and F3 (n = 23) according to the number of positive histopathologic factors, consisting of direct invasion to the liver, invasion to the hepatoduodenal ligament, and lymph node metastasis. Overall survival rates were compared with the Union Internationale Contre le Cancer TNM classification (6th edition). RESULTS Overall 5-year survival rates of patients with F0, F1, F2, and F3 were 60%, 35%, 5%, and 0%, respectively. Significant differences were observed, except between F2 and F3. In 38 patients with F1, there were no significant differences between 13 patients with direct invasion to the liver, 4 patients with invasion to the hepatoduodenal ligament, and 21 patients with lymph node metastasis. Multivariate analysis revealed that F classification was the most important independent risk factor to predict survival. CONCLUSION Patients with advanced GBC are expected to survive long if only 1 of hepatic invasion, hepatoduodenal ligament invasion, or lymph node metastasis is positive.

Arterio-biliary fistula as rare complication of chemoradiation therapy for intrahepatic cholangiocarcinoma

Significant hemobilia due to arterio-biliary fistula is a very rare complication of chemoradiation therapy (CRT) for unresectable intrahepatic cholangiocarcinoma (ICC). Here we report a case of arterio-biliary fistula after CRT for unresectable ICC demonstrated by angiographic examinations. This fistula was successfully treated by endovascular embolization. Hemobilia is a rare complication, but arterio-biliary fistula should be considered after CRT of ICC.

Huge mucinous cystic adenocarcinoma of the pancreas.

pected to be a mucinous cystic adenocarcinoma. We performed en bloc distal pancreatectomy and splenectomy. The macroscopic appearance was consistent with mucinous cystic neoplasm ( fig. 3 ). Microscopy showed epithelium composed of mucin-secreting cells and a dense cellular ovarian-type stroma ( fig. 4 ). Adenocarcinoma was A 41-year-old woman was referred to our hospital for evaluation of an abdominal tumor. Contrast-enhanced CT and MRI showed a cystic tumor, 21 cm in diameter, with internal septa localized in the tail of the pancreas ( fig. 1 ). FDG-PET revealed significantly increased uptake in the solid component ( fig. 2 ). Thus, this tumor was susPublished online: November 10, 2010

T1593 Simultaneous Portal Venous Resection During Pancreatoduodenectomy for Locally Advanced Pancreas Head Cancer

Background and Objectives: Postoperative pancreatic fistula following pancreaticoduodenectomy is relatively common, and remains a major cause of severe complication and surgical mortality. The aim of this study was to evaluate the results of two-layered duct to mucosa pancreaticogastrostomy with internal stent as a method for restoring pancreaticoenteric continuity. Methods: From Dec. 2003 to Oct. 2008, prospectively collected data from 100 consecutive patients who underwent pancreaticoduodenectomy were evaluated. Postoperative pancreatic fistula was assessed using the criteria of International Study Group Pancreatic Fistla (ISGPF). Results: Median drain amylase on day 1 after surgery was 611 IU/L, on day 2 it was 255 IU/L, on day 3 it was 80 IU/L, and on day 5 it was 27 IU/L. Of 100 patients, 13 developed pancreatic fistula; grade A in 11 patients, grade B in 1, and grade C in 1. One re-do operations, but no postoperative percutaneous drainage, and no surgical mortality occurred. By univariate analysis, texture of the remnant pancreas was found to be significantly associated with ISGPF. However, all grade A pancreatic fistula occurred in the patient with soft remnant pancreas and the incidence of clinically significant PF (grade B, C) was 2% (one in soft and one in hard remnant pancreas), there was no significant clinical factor associated with clinically significant pancreatic fistula (ISGPF grade B,C). Conclusions: Two layered duct to mucosa pancreaticogastrostomy with internal stent for restoration of pancreaticoenteric continuity after pancreaticoduodenectomy is associated with a low incidence of clinically significant pancreatic fistula.