Naoto Fukuda

Factors predicting mortality in emergency abdominal surgery in the elderly

ObjectiveThis study aimed to investigate clinical features of abdominal emergency surgery in elderly patients, and to determine factors predicting mortality in these patients.MethodsThe study population included 94 patients aged 80 years or older who underwent emergency surgery for acute abdominal diseases between 2000 and 2010. Thirty-six patients (38.3%) were male and fifty-eight patients (61.7%) were female (mean age, 85.6 years). Main outcome measures included background of the patient’s physical condition (concomitant medical disease, and performance status), cause of disease, morbidity and mortality, and disease scoring system (APACHE II, and POSSUM). Prognostic factors affecting mortality of the patient were also evaluated by univariate analysis using Fisher’s exact test and Mann–Whitney U–test, and by multivariate analysis using multiple logistic regression analysis.ResultsOf the 94 patients, 71 (75.5%) had a co-existing medical disease; most patients had hypertension (46.8%). The most frequent surgical indications were acute cholecystitis in 23 patients (24.5%), followed by intestinal obstruction in 18 patients (19.1%). Forty-one patients (43.6%) had complications during hospital stay; the most frequent were surgical site infection (SSI) in 21 patients (22.3%) and pneumonia in 12 patients (12.8%). Fifteen patients died (overall mortality, 16%) within 1 month after operation. The most common causes of death were sepsis related to pan-peritonitis in 5 patients (5.3%), and pneumonia in 4 patients (4.3%). Multiple logistic regression analysis showed that time from onset of symptoms to hospital admission and the POSSUM scoring system could be prognostic factors for mortality.ConclusionsMortality in elderly patients who underwent emergency surgery for acute abdominal disease can be predicted using the disease scoring system (POSSUM) and on the basis of delay in hospital admission.

Prognostic Significance of the Metastatic Lymph Node Ratio in Gastric Cancer Patients

BackgroundLymph node metastasis is considered one of the most important prognostic factors in gastric cancer. However, the optimal system for accurate staging of lymph node metastasis for patients with gastric cancer remains controversial. This study was designed to investigate the prognostic significance of the metastatic lymph node ratio (MLR), which is calculated by dividing the number of metastatic lymph nodes by the total number of nodes harvested from patients with gastric cancer.MethodsWe retrospectively analyzed the clinical data of 186 consecutive patients diagnosed with gastric cancer who underwent curative gastrectomy at our hospital. The lymph node status was classified according to three systems: the International Union Against Cancer/American Joint Committee on Cancer (UICC/AJCC) system; the Japanese Gastric Cancer Association (JGCA) system; and an MLR-based system (MLR0: 0, MLR1: 0.01–0.19, MLR2: ≥0.2). The influence of the MLR on patient survival was determined using univariate Kaplan-Meier survival analysis, the generalized Wilcoxon test, and analysis with the multivariate Cox proportional hazards model.ResultsThe 5-year survival rate of the patients with MLR0, MLR1, and MLR2 was 88.6%, 59.4%, and 13.4%, respectively. In addition to the MLR, the UICC/AJCC N category, JGCA n category, tumor stage (pT category), and tumor diameter significantly influenced the 5-year survival rate, as determined by univariate analysis. Multivariate analyses revealed that of the three factors used to stage lymph node involvement, MLR was the most significant prognostic factor.ConclusionsThe MLR is an important and easy-to-assess prognostic factor that should be considered for staging lymph node metastasis in patients with gastric cancer.

Prognostic factors of T4 gastric cancer patients undergoing potentially curative resection

AIM To investigate the prognostic factors of T4 gastric cancer patients without distant metastasis who could undergo potentially curative resection. METHODS We retrospectively analyzed the clinical data of 71 consecutive patients diagnosed with T4 gastric cancer and who underwent curative gastrectomy at our institutions. The clinicopathological factors that could be associated with overall survival were evaluated. The cumulative survival was determined by the Kaplan-Meier method, and univariate comparisons between the groups were performed using the log-rank test. Multivariate analysis was performed using the Cox proportional hazard model and a step-wise procedure. RESULTS The study patients comprised 53 men (74.6%) and 18 women (25.4%) aged 39-89 years (mean, 68.9 years). Nineteen patients (26.8%) had postoperative morbidity: pancreatic fistula developed in 6 patients (8.5%) and was the most frequent complication, followed by anastomosis stricture in 5 patients (7.0%). During the follow-up period, 28 patients (39.4%) died because of gastric cancer recurrence, and 3 (4.2%) died because of another disease or accident. For all patients, the estimated overall survival was 34.1% at 5 years. Univariate analyses identified the following statistically significant prognostic factors in T4 gastric cancer patients who underwent potentially curative resection: peritoneal washing cytology (P < 0.01), number of metastatic lymph nodes (P < 0.05), and venous invasion (P < 0.05). In multivariate analyses, only peritoneal washing cytology was identified as an independent prognostic factor (HR = 3.62, 95% CI = 1.37-9.57) for long-term survival. CONCLUSION Positive peritoneal washing cytology was the only independent poor prognostic factor for T4 gastric cancer patients who could be treated with potentially curative resection.

Common bile duct stones: management strategies in the laparoscopic era.

We reviewed our experience with the treatment of common bile duct (CBD) stones in 70 patients by sequential endoscopic-laparoscopic management and single-stage laparoscopic treatment during the past 7 years. The advantages, disadvantages, and feasibility of the two procedures are discussed to elucidate therapeutic strategies for patients harboring gallbladder stones and associated choledocholithiasis. In 44 patients, sequential endoscopic-laparoscopic management was indicatedd, and was successful in 37 of them but, in seven patients endoscopic stone extraction could not be accomplished. Single-stage laparoscopic treatment was attempted in 26 patients. In practice, laparoscopic transcystic common duct exploration or choledochotomy may not always be feasible if the cystic duct or CBD are not dilated; there is a high risk of intraoperative CBD injury in such circumstances. Laparoscopic management was considered to be especially useful for the treatment of numerous, large or difficult stones, because stone removal could be succesfully performed without any injury to the papilla of Vater. This last issue is of particular importance in patients with dilated CBD, because insufficient opening of the ampulla of Vater made by endoscopic sphincterotomy (EST) may lead to stasis and reflux-related complications such as cholangitis and recurrent stones. We conclude that the most rational management of CBD stones should be decided according to the size of the CBD, which depends on the size, number, and location of stones. Patients with dilated CBD are indicated to under-go laparoscopic single-stage treatment and combined endoscopic-laparoscopic treatment may be best for patients with non-dilated CBD.

Xanthogranulomatous cholecystitis: report of a case and literature review on clinical differentiating factors from gallbladder carcinoma

Xanthogranulomatous cholecystitis (XGC) is a rare, benign, destructive inflammatory disease of the gallbladder that is assumed to be a variant of chronic cholecystitis. We herein present a rare case of XGC, which simulates gallbladder carcinoma with extensive involvement of the liver, omentum and the biliary trees. At surgery, total cholecystectomy with partial hepatectomy of the gallbladder bed and excision of adjacent xanthogranulomatous tissue was performed, but bilio‐enteric anastomosis for biliary decompression, which was the procedure preoperatively planned, was impossible to indicate because the common bile duct could not be clearly exposed by its infiltration showing mass formation. Therefore, retrograde transhepatic biliary drainage was eventually indicated for subsequent endoscopic therapy using stent placement to deal with the biliary structure caused by XGC. The patient has been leading a normal life after stent placement in the biliary tract for 6 months duration without any symptoms suggesting biliary stricture. In conclusion, XGC can simulate gallbladder cancer in its clinical presentation, radiological findings and even gross operative features. It is important to make preoperative ultrasound‐guided fine‐needle aspiration cytological diagnosis or intraoperative pathological diagnosis in order to avoid misdiagnosis and unnecessary therapy. Cholecystectomy, excision of adjacent xanthogranulomatous tissue, which often includes partial hepatic resection, are still the best management of XGC.

Moving from lymph node metastasis in gastric cancer to biological markers: reply to letter.

Lymph node metastasis (pN category) and tumor depth invasion (pT category) have been the most important prognostic factors for patients with gastric cancer. In the pN category, although several studies [1–7] have clarified the prognostic significance of the metastatic lymph node ratio (MLR) in gastric cancer, it has not been widely used in clinical practice compared with the UICC/AJCC system commonly used in Western countries and the JGCA system commonly used in Japan. The MLR system has the advantage that it is independent of the number of dissected lymph nodes, which may be affected by the surgeon’s attitude toward lymph node dissection. Moreover, it is simple, convenient, and reproducible for predicting the prognosis as well as for treatment planning. Our study also revealed the superiority of the MLR for evaluating lymph node metastasis in patients with gastric cancer compared with the UICC/AJCC and JGCA systems, although the sample size of the study was small (n = 186). Micrometastases or isolated tumor cells in lymph nodes may also be an effective predictive factor for gastric cancer. Nevertheless, patient deaths due to gastric cancer recurrence after curative gastrectomy with D2 lymphadenectomy might be closely related to the large number of lymph node metastases, more advanced N stage, or high MLR rather than micrometastases or isolated tumor cells in lymph nodes. We think that the pN category, especially the MLR, is the key to making decisions regarding adjuvant treatment for locally advanced gastric cancer after a complete surgical resection (R0). Cases with more advanced lymph node metastasis (e.g., MLR [0.2) should be treated with intensive adjuvant chemotherapy [8, 9] rather than with S-1 [10], which is commonly used as adjuvant chemotherapy for stage 2 or 3 locally advanced gastric cancer in Japan. In fact, we select the adjuvant treatment for locally advanced gastric cancer based on the metastatic lymph node status evaluated by the MLR system. In addition to the MLR, micrometastases, and isolated tumor cells in lymph nodes, a biologic marker—human epidermal growth factor receptor 2 (HER2)—has been recently found to be a prognostic factor for gastric cancer. Indeed, molecular targeting therapy using trastuzumab for advanced HER-2-positive gastric cancer has been reported [11]. I believe that we should move forward and develop new biomarkers, target agents, and novel drugs to improve the prognosis of patients with advanced gastric cancer.