Minoru Esaki

Therapeutic value of lymph node dissection during hepatectomy in patients with intrahepatic cholangiocellular carcinoma with negative lymph node involvement.

BACKGROUND Routine and radical lymph node dissection is a clinical concern for improving the surgical outcome in patients with intrahepatic cholangiocarcinoma (ICC). The therapeutic value of the procedure during hepatectomy has, however, not been evaluated. METHODS Between January 1990 and December 2004, 104 patients with ICC undergoing macroscopic curative resections were investigated retrospectively with special reference to lymph node status. The role of lymph node dissection was evaluated according to macroscopic type: mass-forming (MF) type (n = 68) and MF plus periductal infiltration (PI) type (n = 36) of ICC. RESULTS Lymph node involvement and intrahepatic metastases were an independent, unfavorable prognostic factor in the MF type of ICC. Negative lymph node involvement provided a favorable survival rate in the 41 patients without intrahepatic metastases (P < .0001). Among the 29 patients without lymph node involvement and intrahepatic metastases, there was no difference according to the use of lymph node dissection (P = .8071). Also, no difference was seen with lymph node involvement in the 24 patients with the MF plus PI type of ICC who had no intrahepatic metastases (P = .6620). CONCLUSION For purpose of diagnostic staging and exclusion of positive regional lymph nodes, lymph node dissections might be useful in patients with the MF type and the MF plus PI type of ICC; however, routine use of lymph node dissection in patients with the MF type of ICC is not recommended, because no difference in survival was observed in the patients with negative lymph node metastases, irrespective of the use of lymph node dissection.

Preoperative evaluation of invasive and noninvasive intraductal papillary-mucinous neoplasms of the pancreas: clinical, radiological, and pathological analysis of 123 cases.

Objective: We aimed to investigate preoperative findings that are useful to distinguish intraductal papillary-mucinous neoplasm (IPMN) subtypes. Methods: One hundred twenty-three patients who underwent pancreatectomy for IPMN were analyzed clinicopathologically and radiologically. Invasive IPM carcinomas (IPMCs) were subdivided into early-stage nonaggressive (minimally invasive IPMC [MI-IPMC]) and more advanced and aggressive (invasive carcinoma originating in IPMC [IC-IPMC]) subtypes according to our recently proposed pathological criteria. Results: The lesions consisted of 27 IPMNs with low-grade dysplasia, 14 IPMNs with moderate dysplasia, 21 IPMNs with high-grade dysplasia, 30 MI-IPMCs, and 31 IC-IPMCs. Multidetector-row computed tomography detected a component of invasive carcinoma in IC-IPMC with 86% sensitivity and 100% specificity. In patients with IPMNs other than IC-IPMC, multivariate analysis demonstrated 3 significant predictive factors of malignancy: IPMN size (>40 mm), IPMN duct type (main pancreatic duct or mixed type), and the presence of a mural nodule or thick septum. The diagnostic score obtained using these 3 factors showed a strong correlation with the presence of malignancy. Conclusions: For preoperative evaluation of patients with IPMN, it is recommended to rule out IC-IPMC using multidetector-row computed tomography and then to categorize IPMN other than IC-IPMC according to malignant potential based on the diagnostic score.

Analysis of Prognostic Factors Affecting Survival After Initial Recurrence and Treatment Efficacy for Recurrence in Patients Undergoing Potentially Curative Hepatectomy for Hepatocellular Carcinoma

BackgroundSurvival analysis in patients with initial recurrence after curative hepatectomy for hepatocellular carcinoma (HCC) has not been well evaluated. In addition, selections of the most effective treatments for patients with recurrent HCC still remain controversial.MethodsThree hundred and nineteen patients who underwent potentially curative hepatectomies were followed for initial recurrence, and factors predictive of recurrence were determined. The factors affecting survival including pattern of recurrence and treatment modalities from the time of initial recurrence in 211 patients were retrospectively analyzed.ResultsThe overall 5-year disease-free survival rate of 319 patients was 31.1%. The 5-year survival rate of 211 patients from the time of initial recurrence was 31.9%. In a multivariate analysis, a low indocyanine green retention rate, lack of liver cirrhosis, a long interval before recurrence, the absence of portal vein invasion, and intrahepatic recurrence (≤3 nodules) were shown to be significantly favorable prognostic factors after the initial recurrence. The 5-year survival rate of patients with intrahepatic recurrence (≤3 nodules) was 42.3%, and no survival differences were observed among different treatment modalities.ConclusionWhen the initial recurrence occurred after a longer interval, and/or with three or fewer intrahepatic recurrent nodules, a favorable prognosis could be expected in those patients with better liver function and no portal vein invasion at the time of the primary hepatectomy. It is important to conduct a randomized controlled trial to clarify a method for selecting optimal treatment in patients with a smaller number of initial intrahepatic recurrences.

Is celiac axis resection justified for T4 pancreatic body cancer

BACKGROUND The clinical impact of the distal pancreatectomy with en-bloc celiac axis resection for locally advanced pancreatic body cancer remains unclear. METHODS We reviewed the records of 13 patients who underwent distal pancreatectomy-celiac axis resection between 1991 and 2009, 58 patients who underwent distal pancreatectomy for pancreatic body cancer involving major vessels, the extrapancreatic neural plexus or other organs (T4 according to the Japanese stage classification) between 1991 and 2009, and 24 patients with unresectable locally advanced pancreatic cancer without distant metastases (unresectable group) between 2001 and 2009. The clinicopathologic factors and overall survival among the 3 groups were compared. RESULTS The distal pancreatectomy-celiac axis resection group was associated with a significantly higher incidence of morbidity (92% vs 60%, P = .03) and positive surgical margins (69% vs 26%, P = .003) than the distal pancreatectomy group; however, no survival difference was found between the 2 groups. No survivor has lived more than 3 years after operation in the distal pancreatectomy-celiac axis resection group. The distal pancreatectomy-celiac axis resection group had a significantly better prognosis than the unresectable group (median survival time, 20.8 vs 9.8 months; P = .01). CONCLUSION Aggressive resection for T4 pancreatic body cancer by distal pancreatectomy-celiac axis resection can be justified for otherwise unresectable tumors. The surgical indication should be evaluated carefully because of the higher incidence of morbidity and lower incidence of curability compared with distal pancreatectomy, as well as because there have been no long-term survivors so far.

Analysis of risk factors for delayed gastric emptying (DGE) after 387 pancreaticoduodenectomies with usage of 70 stapled reconstructions.

BackgroundDelayed gastric emptying (DGE) is one of the most troublesome complications after pancreaticoduodenectomy (PD).MethodsBetween 2004 and 2009, 387 patients underwent PD and of these, 302 patients (78%) underwent pylorus-preserving PD. The stapled reconstruction of duodeno- or gastrojejunostomy was introduced in 2006, and 70 patients (18%) underwent stapled Roux-en-Y reconstruction. Postoperative DGE was defined based on the International Study Group on Pancreatic Surgery classification, and grade B or C DGE was considered to be clinically relevant. Risk factors for DGE were evaluated using univariate and multivariate analyses.ResultsFour patients died in the hospital (1.0%). Postoperative DGE was found in 70 patients (18%). DGE was less frequently seen in stapled reconstruction than in hand-sewn reconstruction (7.2% vs. 21%, P < 0.001), and in single-layer anastomosis than in double-layer anastomosis (12% vs. 24%, P = 0.02). The multivariate logistic regression analysis revealed that the independent risk factors for DGE were postoperative pancreatic fistula (risk ratio [RR] 2.4, P = 0.002), hand-sewn reconstruction (RR 2.9, P = 0.03) and male (RR 2.2, P = 0.02).ConclusionThe method of alimentary reconstruction affected the occurrence of DGE. The incidence of DGE was less in stapled reconstruction than in hand-sewn reconstruction.

Is extended hemihepatectomy plus pancreaticoduodenectomy justified for advanced bile duct cancer and gallbladder cancer

BACKGROUND Major hepatopancreaticoduodenectomy (HPD) is an extensive surgical procedure offering the highest curability for patients with advanced biliary cancer. However, surgical morbidity associated with major HPD is high, and optimal indications for this procedure remain unclear. METHODS Between 1989 and 2010, 14 patients with widespread bile duct cancer and 5 with gallbladder cancer having biliary infiltration underwent major HPD at our hospital. Preoperative portal vein embolization was performed in 17 patients undergoing right HPD. Clinicopathologic factors and survivals following HPD were compared between patients with bile duct cancer and those with gallbladder cancer. RESULTS One patient who underwent right HPD for gallbladder cancer died of hepatic failure (5.3%) and 18 of the 19 patients (95%) developed postoperative pancreatic fistulas. The median hospital stay was 47 days. Depth of invasion was T3 in 1 patient and T4 in 2 patients with bile duct cancer and was T4 in all 5 patients with gallbladder cancer (P = .002). The clinical stage was IV in 3 patients (21%) with bile duct cancer and in all 5 patients with gallbladder cancer (P = .002). The 5-year survival rates and median survival rates of patients with bile duct cancer and gallbladder cancer were 45% vs 0 and 3.3 years vs 8 months, respectively (P < .001). CONCLUSION HPD can be an acceptable treatment option for widespread bile duct cancer. However, the indication for HPD in advanced-stage gallbladder cancer should be considered carefully, considering the high morbidity rate and the advanced stage of the disease.

Efficacy of a Hepatectomy and a Tumor Thrombectomy for Hepatocellular Carcinoma with Tumor Thrombus Extending to the Main Portal Vein

IntroductionHepatocellular carcinoma (HCC) with major portal tumor thrombus has been considered to be a fatal disease. A thrombectomy remains the only therapeutic option that offer a chance of complete tumor removal avoiding acute portal vein obstruction. However, the efficacy of tumor thrombectomy in addition to hepatectomy has not been well evaluated.MethodsOf 979 patients who consecutively underwent initial HCC resection, 45 (4.6%) HCC patients with tumor invasion of the first branch of the portal vein (vp3) and tumor in the main portal trunk or the opposite-side portal branch (vp4) were retrospectively analyzed to evaluate the efficacy of hepatectomy and tumor thrombectomy.ResultsAlpha-fetoprotein, serosal invasion, and intrahepatic metastases were independently significant prognostic factors in all the 45 patients with vp3 or vp4 HCC. The 3- and 5-year survival rates in vp3 and vp4 group were 35.3% and 41.8%, and 21.2% and 20.9%, respectively. There were longer operative times and more intraoperative bleeding in patients with vp4, but no significant difference in mortality, morbidity, and survival between patients with vp3 and vp4.ConclusionHepatectomy and thrombectomy for vp4 could not only avoid acute portal occlusion due to tumor thrombus but provide a comparable survival benefit with hepatectomy for vp3.

Intrapancreatic nerve invasion as a predictor for recurrence after pancreaticoduodenectomy in patients with invasive ductal carcinoma of the pancreas.

Background: Neural invasion is a distinct route for the spread of pancreatic carcinoma. However, the clinicopathologic significance of neural invasion, with particular reference to intrapancreatic nerve invasion, remains to be elucidated. Methods: One hundred fifty-three patients who underwent pancreaticoduodenectomy for invasive ductal carcinoma of the pancreas between 2004 and 2008 were retrospectively examined. The clinical and histopathologic factors, including intrapancreatic nerve invasion, were analyzed in these patients. The relationships between the degree of intrapancreatic nerve invasion and disease-free survival, as well as various histopathologic factors, were investigated. Results: There were significant differences in the degree of intrapancreatic nerve invasion with regard to disease-free survival (P < 0.001). A lack of lymph node metastases (P = 0.001), lower incidence of intrapancreatic nerve invasion (P = 0.001), and negative surgical margin (P = 0.011) significantly increased the disease-free survival. The tumor stage was not associated with intrapancreatic nerve invasion (P = 0.255). However, a larger tumor size (P = 0.024), a higher incidence of lymphatic invasion (P = 0.036), and the presence of extrapancreatic nerve plexus invasion (P < 0.001) were identified as independent factors associated with a higher incidence of intrapancreatic nerve invasion. Conclusions: Intrapancreatic nerve invasion may be useful as a predictor for recurrence after pancreaticoduodenectomy in patients with invasive ductal carcinoma of the pancreas.

Role of Medial Pancreatectomy in the Management of Intraductal Papillary Mucinous Neoplasms and Islet Cell Tumors of the Pancreatic Neck and Body

Background/Aim: Medial pancreatectomy has been applied as a safe and effective alternative in benign diseases located in the pancreatic neck or body. However, the role of this procedure remains controversial. We investigate outcomes using this method in 14 patients. Methods: Fourteen consecutive patients underwent medial pancreatectomy. The surgical indications, postoperative outcomes, and pathologic characteristics were retrospectively analyzed. Results: Among 10 patients with intraductal papillary mucinous neoplasms, 3 patients had minimally invasive adenocarcinoma, and 3 had adenocarcinoma in situ. Four patients required an additional resection of the pancreatic remnant because of a positive surgical margin. A medial pancreatectomy was converted to a distal pancreatectomy in 1 patient with adenocarcinoma in situ. Three patients with islet cell tumor and 1 patient with solid pseudopapillary tumor had no malignant disease. Postoperative complications occurred in 6 patients (43%): 5 had pancreatic fistulas and 1 had a gastric ulcer. All of the patients are doing well without recurrence. Conclusions: A medial pancreatectomy is a safe and effective alternative for the treatment of intraductal papillary mucinous neoplasm, islet cell tumor, or solid pseudopapillary tumor located in the neck or body of the pancreas. However, a precise preoperative and intraoperative assessment including an examination of frozen sections is mandatory to select the appropriate surgical procedure.

Role of the width of the surgical margin in a hepatectomy for small hepatocellular carcinomas eligible for percutaneous local ablative therapy

BACKGROUND There is intense clinical interest to determine whether a wide surgical margin is required to improve postoperative recurrence after locoregional therapy for small hepatocellular carcinomas (HCCs). METHODS From 1996 to 2003, 117 patients with small HCCs, and also matching the criteria for local ablation therapy (up to 3 nodules </=30 mm in size), were analyzed retrospectively to determine the prognostic factors affecting postoperative recurrence. RESULTS The number of tumors and the surgical margin status were independent factors influencing the disease-free survival. The wide surgical margin status (>/=10 mm) provided a favorable disease-free survival in the 39 patients with negative hepatitis C virus infection (P = .0020) in the 59 patients with larger tumor size (>/=25 mm) (P = .0265) and in the 60 younger patients (</=63 y) (P = .0103). CONCLUSIONS A surgical margin (>/=10 mm) should be secured in young patients without hepatitis C virus infection and/or a tumor size of 25 mm or larger because long-term disease-free survival could be expected after a macroscopic curative hepatectomy for small HCCs.