Naokazu Chiba

Computer assisted surgery, preoperative planning and navigation for pancreatic cancer.

Currently, the best treatment for locally advanced pancreatic cancer is considered to be safe and effective surgery, followed by appropriate additional therapies implemented as quickly as possible. The use of diagnostic imaging to assist surgery is being researched in a range of institutions. This report introduces the results of a study into the optimized contrast conditions for computed tomography (CT)‐volume rendering image generation, effective in providing image support for pancreatic surgery, and introduces actual cases in which imaging support was used in surgery. The authors demonstrated that the conventional contrast protocols used in making a diagnosis are not necessarily the optimum protocols for image creation. It is thought that the use of image‐supported surgery will improve the safety and effectiveness of pancreatic surgery.

Predicting hepatic failure with a new diagnostic technique by preoperative liver scintigraphy and computed tomography: a pilot study in 123 patients undergoing liver resection

BackgroundA novel index, total liver LU15, has been identified as a surrogate marker for liver function. We evaluated the ability of preoperative remnant liver LU15 values to predict postoperative hepatic failure.MethodsPreoperative risk factors for postoperative hepatic failure and remnant liver LU15 were evaluated in 123 patients undergoing liver resection for several diseases from September 1st, 2007 to December 1st, 2016. We calculated the remnant liver LU15 value from the total liver LU15 value and the functional remnant liver ratio. Risk factors for postoperative hepatic failure was determined by univariate and multivariate analysis.ResultsHepatic failure grade B/C developed postoperatively in six patients of seven patients within Makuuchi criteria / without criteria for remnant liver LU15. Operative time (pu2009=u20090.0242) and criteria for remnant liver LU15 (pu2009=u20090.0001) were prognostic factors for hepatic failure according to the univariate analysis. And criteria for remnant liver LU15 (pu2009=u20090.0009) was only prognostic factor by multivariate analysis.ConclusionBased on the findings form this pilot study, it appears that patients with a remnant liver LU15 value of 13 or less may have a high risk of postoperative hepatic failure.

Increased expression of HOXB9 in hepatocellular carcinoma predicts poor overall survival but a beneficial response to sorafenib

At advanced stages of hepatocellular carcinoma (HCC), the multikinase inhibitor sorafenib is the only effective treatment. Surrogate markers that predict the biological and clinical efficacy of sorafenib may help tailor treatment on an individual patient basis. In the present study, the clinical significance of the expression of HOXB9, a transcriptional factor, in HCC was assessed. Increased HOXB9 expression in HCC was found to be positively correlated with the expression of angiogenic factors, increased vascular invasion and was found to be associated with poor overall patient survival. Sorafenib treatment effectively suppressed the expression of angiogenic factors and activation of the Raf/MEK/ERK pathway in HOXB9-expressing HCC cell lines. Consistent with these findings, HCC patients, whose cancer expressed high levels of HOXB9, exhibited increased overall survival upon sorafenib treatment. Collectively, these results suggest that HOXB9 expression in HCC could be a surrogate marker for a beneficial response to sorafenib treatment.

Synergistic Effects of Calcineurin Inhibitors and Steroids on Steroid Sensitivity of Peripheral Blood Mononuclear Cells.

The steroid receptor (SR) complex contains FKBP51 and FKBP52, which bind to tacrolimus (TAC) and cyclophilin 40, which, in turn, bind to cyclosporine (CYA); these influence the intranuclear mobility of steroid-SR complexes. Pharmacodynamic interactions are thought to exist between steroids and calcineurin inhibitors (CNIs) on the SR complex. We examined the effect of CNIs on steroid sensitivity. Methylprednisolone (MPSL) sensitivity was estimated as the concentration inhibiting mitosis in 50% (IC50) of peripheral blood mononuclear cells and as the area under the MPSL concentration-proliferation suppressive rate curves (CPS-AUC) in 30 healthy subjects. MPSL sensitivity was compared between the additive group (AG) as the MPSL sensitivity that was a result of addition of the proliferation suppressive rate of CNIs to that of MPSL and the mixed culture group (MCG) as MPSL sensitivity of mixed culture with both MPSL and CNIs in identical patients. IC50 values of MPSL and cortisol sensitivity were examined before and 2 months after CNI administration in 23 renal transplant recipients. IC50 and CPS-AUC values of MPSL were lower in the MCG than in the AG with administration of TAC and CYA. The CPS-AUC ratio of MCG and AG was lower in the TAC group. IC50 values of MPSL and cortisol tended to be lower after administration of TAC and CYA, and a significant difference was observed in the IC50 of cortisol after TAC administration. Steroid sensitivity increased with both TAC and CYA. Furthermore, TAC had a greater effect on increasing sensitivity. Thus, concomitant administration of CNIs and steroids can increase steroid sensitivity.

The diagnostic value of 99m-Tc GSA scintigraphy for liver function and remnant liver volume in hepatic surgery: a retrospective observational cohort study in 27 patients

BackgroundThe aim was to analyze hepatic hypertrophy after portal vein embolization (PVE) and Associating Liver Partition with Portal vein ligation for Staged hepatectomy (ALPPS) to determine whether clinical circumstances associated with major hepatic resections correlated with remnant growth.MethodsData was abstracted from a retrospectively maintained database on 27 patients undergoing hepatic resection followed by PVE and the ALPPS procedure between October 1, 2007 and December 31, 2016. The increasing rate of liver volume and remnant liver LU15 was defined as the percentage-point difference between the liver volume and remnant liver LU15 before and after the intervention or surgery. And correlation between kinetic growth rate (KGR) of liver and future remnant liver volume or remnant liver LU15 was analyzed.ResultsThe degree of hypertrophy (DH) of volume and LU15 was significantly greater after ALPPS (volume: 40.3% and LU15: 65.0%) than after PVE (volume: 22.7% and LU15: 48.8%) (Pxa0<u20090.05). KGR of volume and LU15 was significantly greater after ALPPS (volume: 19.0xa0cm3/day and 2.00%/day) (LU15: 0.61 /day and 1.82%/day) than after PVE (volume: 3.89xa0cm3/day and 0.42%/day) (LU15: 0.19 /day and 0.63%/day) (Pxa0<u20090.001). An inverse correlation between KGR and initial remnant liver volume was observed. And a positive correlation between KGR and LU15 was observed.ConclusionFuture remnant liver volume and KGR was greater after the ALPPS procedure than after PVE. Liver hypertrophy is related to the expected remnant liver volume and total liver function. This study suggested that total liver function and initial remnant liver volume might be a new indication of hepatectomy after PVE and ALPPS in the case of insufficient remnant liver volume.

The preliminary role of circulating tumor cells obtained from the hepatic or portal veins in patients with hepatobiliary–pancreatic cancer

SummaryBackgroundMetastases, which result from circulating tumor cells (CTC) that have detached from the primary cancer and survived in distant organs, cause the majority of cancer deaths. The present study aimed to assess the prognostic relevance of CTC in patients with hepatobiliary–pancreatic cancer.MethodsAxa0total of 30xa0consenting patients were enrolled. Pre-resection blood samples were obtained from the hepatic or portal veins of patients, respectively. CTCs were analyzed using the CellSearch system and isolated using antibodies against the epithelial cell adhesion molecule and cytokeratin. Patients were separated into 2xa0groups based on their CTC counts. The CTC-positive group included patients with baseline CTC counts >10/7.5xa0ml.ResultsOf the 30xa0patients, 12 (40u2009%) were considered CTC positive. CTC-positive patients had axa0shorter 1‑year progression-free survival (PFS) than CTC-negative patients (71.1u2009% vs. 36.4u2009%, pxa0= 0.0324); however, no difference was observed in the 3‑year overall survival (47.1u2009% vs. 45.5u2009%, pxa0= 0.7576). In particular, CTC-positive pancreatic carcinoma patients had axa0shorter 1‑year PFS (22.2u2009% vs. 0.0u2009% for CTC-negative, pxa0= 0.0018).ConclusionsElevated CTC from hepatic or portal veins might predict axa0shorter PFS in patients with hepatobiliary–pancreatic cancer, particularly those with pancreatic carcinoma.

Long-term survival of a recurrent gallbladder carcinoma patient with lymph node and peritoneal metastases after multidisciplinary treatments: a case report

BackgroundGallbladder carcinoma with peritoneal metastasis has a poor prognosis, with a median survival time of 4.8 months. We report the survival of a patient with gallbladder carcinoma with peritoneal metastasis for 7.6 months owing to treatment with tumor resection after chemoradiotherapy.Case presentationA 69-year-old man was referred to our hospital for gallbladder carcinoma with hepatic invasion. Cholecystectomy was performed along with S4a and S5 hepatectomy and extrahepatic bile duct resection with lymph node dissection. The postoperative pathological diagnosis was moderately differentiated adenocarcinoma, T3, N0, M0, stage IIIA by the International Union Against Cancer TNM classification. Despite treatment with gemcitabine, the common hepatic artery and para-aortic lymph nodes showed metastases after 3xa0months from surgery. Although a combination of cisplatin, gemcitabine, and radiotherapy reduced the size of the lymph node metastasis, the peritoneal metastasis persisted. The peritoneal metastasis responded to chemoradiotherapy using tegafur-uracil and leucovorin, but it recurred. The metastasis was resected after 3xa0years and 9xa0months from the first surgery, and chemotherapy was discontinued. Seven years and 6xa0months after the initial surgery, the patient exhibited no signs of tumor recurrence or metastasis.ConclusionsMultidisciplinary treatment including resection without residual tumors could achieve complete remission of gallbladder carcinoma with lymph node and peritoneal metastases in the selected patient.

Adult Living-Donor Liver Transplantation for a Recipient With a High Preoperative 1,3-Beta-d-Glucan Level and Positive Test Result for Aspergillus Antigen

The patient was a 45-year-old man with underlying alcoholic liver cirrhosis. Two years prior, he was repeatedly hospitalized for liver failure symptoms and requested a living-donor liver transplantation (LDLT) because of end-stage cirrhosis. A pretransplantation blood test revealed a high 1,3-beta-d-glucan (BDG) value of 102.0 pg/mL (reference value <20.0 pg/mL) and a high blood Aspergillus antigen (AsAg) value of 1.6 cutoff index (COI; reference value <0.5 COI). Contrast-enhanced thoracoabdominal-pelvic computed tomography (CT) and cranial magnetic resonance imaging revealed no fungal infection. However, latent fungal infection could not be ruled out, hence preoperative antifungal agent treatment was administered. BDG and AsAg levels showed a decreasing trend after treatment initiation. However, normalization did not occur; the BDG and AsAg levels were 25.8 pg/mL and 1.0 COI, respectively. Although the possibility of latent fungal infection was judged low, we prophylactically administered antifungal agents after LDLT. The BDG level consistently increased at 35-39 pg/mL until postoperative day 5 but subsequently normalized. The AsAg level was higher than the limit of detection at 5.0 COI on postoperative day 3 but normalized to 0.2 COI on postoperative day 5 and did not subsequently increase. The postoperative course was uneventful despite bacterial pneumonia and the patient was discharged on postoperative day 35. A histopathologic examination (Grocott methenamine silver staining) and a fungal polymerase chain reaction assay were performed for the resected liver, but the results of both were negative. At 9 postoperative months, the patient was making ambulatory follow-up visits. Currently, the BDG and AsAg values remain normal and clinical progress is favorable. We found no reports of LDLT for a recipient with a high preoperative BDG level and positive test result for AsAg. Thus, we report on such a case with a discussion of the literature on the causes of high preoperative BDG and AsAg values.

Lymph node metastasis from colon carcinoma at 11 years after the initial operation managed by lymph node resection and chemoradiation: A case report and a review of the literature

INTRODUCTIONnLymph node metastasis from colorectal cancer after a disease-free interval (DFI) of >5years is extremely rare, and occurs in <0.6% cases.nnnPRESENTATION OF CASEnA 60-year-old man underwent low anterior resection for sigmoid colon cancer. The lesion was an adenocarcinoma with no lymph node metastasis of Stage II. At 9years after the colectomy, he was diagnosed with prostate cancer and was treated with radiation and hormonal therapies; at 11years, he exhibited suddenly elevated carcinoembryonic antigen levels. Computed tomography (CT) and positron emission tomography-CT revealed a 2.0-cm para-aortic lymph nodes swelling invading the small intestine. These lymph nodes and the affected segment of the small intestine were resected, and histopathology of the resected specimen confirmed a metastatic tumor. The patient was administered radiation therapy after 22 cycles of 5-fluorouracil, oxaliplatin and leucovorin. He however presented with a residual lesion in the para-aortic lymph node, but currently, he has been symptom free for 4years.nnnDISCUSSIONnA review of the literature indicates that the median survival of all previously reported patients is 12months, and that colon cancer with a long DFI might be a slow growing. One of these patients and our patient both had received radiation and/or hormonal therapy for another cancer, which probably impaired their immune systems, thus resulting in metastatic tumors.nnnCONCLUSIONnWe report a case of lymph node metastasis after a DFI of >5years and review relevant literature to assess the significance and possible reasons for delayed colorectal cancer metastases.

Superficial Surgical Site Infection in Hepatobiliary-Pancreatic Surgery: Subcuticular Suture Versus Skin Staples

PurposePostoperative superficial surgical site infection is a major complication in hepatobiliary-pancreatic surgery. We aimed to compare the efficacy of subcuticular sutures versus staples for skin closure in preventing superficial surgical site infection in hepatobiliary-pancreatic surgery.MethodsConsecutive patients who underwent hepatobiliary-pancreatic surgery at our hospital from October 2006 to March 2011 and from April 2012 to March 2015 were reviewed retrospectively. Superficial surgical site infection incidence was evaluated in patients who received subcuticular sutures and those who received staples for skin closure. Propensity score matching analysis was used to adjust bias from confounding factors.ResultsA total of 691 patients were included. Patients with skin staple closures (nu2009=u2009346) were compared with patients with subcuticular suture closures (nu2009=u2009345). After a propensity score matching analysis, a significant difference in superficial surgical site infection incidence was found between the skin stapler group (11.3%) and subcuticular sutures group (2.6%). The same comparison was performed by a subgroup analysis and supported this finding in patients after hepatectomy without biliary reconstruction, pancreatoduodenectomy, or open laparotomy surgeries and in patients with body mass index <u200925.ConclusionsSubcuticular suturing after hepatobiliary-pancreatic surgery was more efficacious in reducing postoperative superficial surgical site infection incidence than staples for skin closure.