Norihiro Yuasa

Surgical anatomy of the bile ducts at the hepatic hilum as applied to living donor liver transplantation.

Objective:To evaluate anatomic variations of the biliary tree as applied to living donor liver transplantation. Summary Background Data:Anatomic variability is the rule rather than the exception in liver surgery. However, few studies have focused on the anatomic variations of the biliary tree in living donor liver transplantation in relation to biliary reconstruction. Methods:From November 1992 to June 2002, 165 patients underwent major hepatectomy with extrahepatic bile duct resection; right-sided hepatectomy in 110 patients and left-sided hepatectomy in 55. Confluence patterns of the intrahepatic bile ducts at the hepatic hilum in the surgical specimens were studied. Results:Confluence patterns of the right intrahepatic bile ducts were classified into 7 types. The right hepatic duct was absent in 4 of the 7 types and in 29 (26%) of the 110 livers. Confluence patterns of the left intrahepatic bile ducts were classified into 4 types. The left hepatic duct was absent in 1 of the 4 types and in 1 (2%) of the 55 livers. Conclusions:In harvesting the right liver from a donor without a right hepatic duct, 2 or more bile duct stumps will be present in the plane of transection in the graft in 3 patterns based on their relation to the portal vein. Accurate knowledge of the variations in the hepatic confluence is essential for successful living donor liver transplantation.

Expression of CD109 in human cancer

It was recently reported that the human CD109 gene encodes a glycosyl-phosphatidylinositol-anchored glycoprotein that is a member of the α2-macroglobulin/C3, C4, C5 family of thioester-containing proteins. In this study, we found that the expression of mouse CD109 gene was upregulated in NIH3T3 cells expressing RET tyrosine kinase with a multiple endocrine neoplasia 2B mutation. Northern blot analysis showed a high level of expression of the CD109 gene only in the testis in normal human and mouse tissues. In addition, its expression was high in some human tumor cell lines, which included squamous cell carcinoma and glioblastoma cell lines, whereas it was undetectable in neuroblastoma and small-cell lung carcinoma cell lines. When CD109 expression was examined in 33 cases of human lung cell carcinomas by quantitative RT–PCR, a significant high expression of CD109 was detected in about half of squamous cell carcinomas examined, but not in adenocarcinoma, large-cell carcinoma and small-cell carcinoma. Similarly, upregulation of CD109 was observed in nine out of 17 esophageal squamous cell carcinomas. Thus, these results suggested that CD109 might be a useful molecular target for the development of new therapeutics for malignant tumors, such as squamous cell carcinoma.

Factors Influencing Postoperative Hospital Mortality and Long-term Survival after Radical Resection for Stage IV Gallbladder Carcinoma

Factors influencing postoperative hospital mortality and long-term survival after radical resection of stage IV gallbladder carcinoma remain unclear. The objective of this study was to identify characteristics of patients who are good candidates in terms of surgical risk and long-term survival for radical resection of stage IV gallbladder carcinoma. A retrospective study was made of attempted surgical cure in 72 patients with stage IV gallbladder carcinoma. There were 14 postoperative hospital deaths (19%). Eleven (19%) of the 58 patients discharged from hospital survived for more than 3 years. Multivariate analysis indicated male gender, extended right hepatic lobectomy in a cholestatic liver, and portal vein resection as independent risk factors that correlated with hospital death. Distant metastasis was the sole independent factor that related negatively with long-term survival by multivariate analysis. Subset analysis was performed with combinations of the four independent factors obtained by multivariate analyses. The hospital mortality rate and the 3-year survival rate in the 44 patients without portal vein involvement were 9% and 28%, respectively, and were 3% and 27%, for the 31 women in this group. The highest 3-year survival rate (39%) was observed in the 26 patients without distant metastasis and portal vein involvement, despite a hospital mortality rate of 12%. Better patient selection may improve the outcome of radical surgery for stage IV gallbladder carcinoma. These data may be useful in designing future trials of the surgical treatment of advanced gallbladder carcinoma.

Acid and Duodenogastroesophageal Reflux after Esophagectomy with Gastric Tube Reconstruction

OBJECTIVE:Patients who undergo esophagectomy with gastric tube reconstruction incur increased risk for acid reflux and duodenogastroesophageal reflux. Few postesophagectomy studies of gastroesophageal reflux disease have included simultaneous 24-h pH and bilirubin monitoring. The aim of this study is to evaluate acid reflux and duodenogastroesophageal reflux after esophagectomy with gastric tube reconstruction.METHODS:Reflux symptom evaluation, endoscopy, and simultaneous 24-h pH and bilirubin monitoring in the cervical esophagus were performed in 25 patients who underwent Ivor Lewis esophagectomy, intrathoracic esophagogastrostomy, and digital dilation of the pyloric ring as treatment for esophageal cancer.RESULTS:Reflux symptoms were severe, mild, and absent in 2, 7, and 16 patients, respectively. Reflux esophagitis and Barretts esophagus was observed in 11 and 1 patients, respectively. Elevated acid reflux occurred in 7 patients (28%). Elevated duodenogastroesophageal reflux was recorded in 11 patients (44%). Reflux profile analysis identified three patterns: 4 subjects (16%) with both elevated acid reflux and duodenogastroesophageal reflux; 3 (12%) with only elevated acid reflux; and 7 (28%) with only elevated duodenogastroesophageal reflux. Of 7 patients with only elevated duodenogastroesophageal reflux, 4 developed reflux esophagitis. Although reflux symptoms did not correlate with endoscopic esophagitis, a significant correlation was observed between endoscopic esophagitis and acid reflux and/or duodenogastroesophageal reflux.CONCLUSIONS:Reflux symptoms represented a poor indication of esophagitis in patients with esophagectomy and gastric tube reconstruction. Simultaneous 24-h pH and bilirubin monitoring can help in identifying patients at high risk for reflux esophagitis, as well as indicating the cause of esophagitis.

Clinicopathologic Comparison of Siewert Type II and III Adenocarcinomas of the Gastroesophageal Junction

BackgroundSince Misumi et al. and Siewert proposed a new classification for carcinoma of the gastroesophageal junction (GEJ), few surgical studies using these criteria have been reported from Eastern countries. Siewert type II adenocarcinomas are managed using general rules for either gastric or esophageal cancer. We set out to determine whether type II adenocarcinoma is a distinct clinical entity requiring a more specific treatment plan.MethodsAmong 125 Japanese patients who underwent resection of adenocarcinoma of the GEJ (type I, 2; type II, 44; type III, 79), 101 who underwent R0 resections (type II, 40; type III, 61) were analyzed to evaluate surgical results and compare clinicopathologic factors.ResultsBarrett’s epithelium was recognized in two patients with type II adenocarcinoma. Type II differed significantly from type III in higher prevalence of Borrmann macroscopic type 2, more frequent lymph node metastasis (58% vs. 34%), higher metastatic rate to lower mediastinal lymph nodes (13%), increased risk of hepatic recurrence, and lower 5-year survival after R0 resection (67.4% vs. 87.1%).ConclusionsClinicopathologic differences were evident between type II and III adenocarcinomas. Siewert type II adenocarcinoma differs sufficiently to be considered a clinical entity distinct and independent from type III.

Treatment of spontaneous esophageal rupture with a covered self-expanding metal stent.

Spontaneous esophageal rupture is a life-threatening condition requiring immediate treatment. Surgical treatment usually is required, but conservative treatment can be pursued in selected cases.1,2 Covered self-expanding metal stents have proven useful in palliating malignant esophageal perforations and fistulas, but such implants seldom have been used in cases of benign esophageal rupture.3-5 We operated on a 56-year-old man with spontaneous esophageal rupture; when his general condition deteriorated after surgery, a covered self-expanding metal stent was placed to seal the persistent esophageal leak. After the procedure the patient’s vital signs stabilized, and the stent was removed safely by endoscopy 28 days later. Stent placement may be indicated in other similar cases.

A Study of the Subvesical Bile Duct (Duct of Luschka) in Resected Liver Specimens

BackgroundInjury to the duct of Luschka is associated with biliary fistula from the gallbladder bed after cholecystectomy. However, few studies have reported on the detailed anatomy. We elucidated the anatomy and frequency of the duct of LuschkaMethodsA total of 128 specimens from patients who underwent right hepatectomy or more extensive right-sided liver resection between February 1992 and December 2003 were examined. Specimens were fixed in formalin, and serial sections were prepared to trace the course of the bile ducts from the subsegmental branch level.ResultsThe duct of Luschka was observed in 6 (4.6%) specimens. The sites of confluence were as follows: right anterior inferior dorsal branch (2 patients), right anterior branch (2 patients), right hepatic duct (1 patient), and common hepatic duct (1 patient). The upstream end was located in the liver parenchyma of the right anterior inferior dorsal subsegment (5b) and connective tissue of the gallbladder bed in 4 and 2 specimens, respectively.ConclusionsThe duct of Luschka never crosses the segmental (5b) border. Therefore, its upstream region may not be injured by segmentectomy or more extensive liver resection. However, it is possible to injure the duct of Luschka at the common hepatic duct, even if right-sided hepatectomy is performed, as the sites of confluence included the common hepatic duct.

Survival after surgical treatment of early gastric cancer, surgical techniques, and long-term survival

Early gastric cancer (EGC) is well accepted as having a favorable prognosis after surgical treatment. Difference in treatment strategies for EGC between Japan and western countries indicates a need for current information to be evaluated with regard to long-term survival rates of EGC patients throughout the world. To analyze survival rates and recurrence after resection of EGC, we investigated 51 reports in English that each included more than 50 cases of EGC treated by gastrectomy and had been published during the past 12 years (1992–2003). Prevalence of EGC among all gastric cancers was 45%–51% in Japan, but only 7%–28% in western countries. Mean age at diagnosis was less than 60 years in Japan and Korea, but was more than 60 in most of the Western countries. Actuarial and disease-specific 5-year survival rates for EGC were 72%–95.8% and 88%–98.3%, respectively. Those for EGC that were invading the submucosal layer were 71.6%–94.1% and 82%–96.6%, respectively. Those for EGC with lymph node metastasis were 57%–89.1% and 72%–93.5%, respectively. Prevalence of recurrence ranged from 1.0% to 13.8%. Larger clinical series with more EGC cases showed a lower prevalence of recurrence (P=0.531, P=0.0026). Liver and blood-borne distant metastasis represented the predominant pattern of relapse, accounting for over half (54%). Local recurrence and peritoneal dissemination represented 20% and 18% of all recurrences, respectively. Clinicopathological studies have shown lymph node metastasis to be closely related to depth of invasion, size of lesion, histological type, presence of ulcer or ulcer scar, and vessel involvement. Information on these factors is the key to successful treatment of EGC. When sufficient information has been assessed preoperatively, surgeons can select patients for whom less-invasive surgery should not increase the risk of recurrence.

Sphincter of Oddi motility in patients with bile duct stones. A comparative study using percutaneous transhepatic manometry.

The motility of the sphincter of Oddi was measured by percutaneous transhepatic manometry of the sphincter of Oddi (PTMSO) in three groups of 57 patients with bile duct stones. The three groups were: (1) cholecystectomy group (N=10)—patients with common bile duct stones (CBDS) who had already undergone cholecystectomy; (2) noncholecystectomy group (N=37)—patients with CBDS who had not undergone cholecystectomy; and (3) intrahepatic stone (IHS) group (N=10). The basal pressure, amplitude, frequency, and propagation direction of contraction waves and the response to cerulein injection or dried egg yolk ingestion were analyzed and compared among these groups. No significant differences in the basal pressure, amplitude, frequency, and propagation direction of the contraction waves were found among the three groups. There were also no differences in the response to cerulein or dried egg yolk ingestion. The frequency and duration of the burst contractions occurring in duodenal phase III of the migrating motor complex were significantly higher (P<0.05) in the cholecystectomy group than in the other two groups. These two differences in the burst contractions may be ascribed to the absence of the gallbladder.

Clinicopathological features of superficial spreading and nonspreading squamous cell carcinoma of the esophagus

OBJECTIVES:Superficially spreading carcinoma of the esophagus, consisting mainly of intraepithelial carcinoma, is not as rare as was previously thought. Despite the surgical significance of this entity, no general definition has been established, and the clinical features of this disease remain to be clarified.METHODS:A total of 54 patients with superficial carcinoma of the esophagus (defined as carcinoma limited to the epithelium or superficially invading the lamina propria or submucosa) were classified into two groups according to the longitudinal extent of the lesion. A total of 13 patients with superficially spreading carcinoma (defined as a superficial carcinoma measuring >5 cm and consisting mainly of intraepithelial carcinoma) were compared to 41 patients with nonspreading esophageal carcinoma.RESULTS:One patient with superficially spreading carcinoma had a positive resection margin because of multiple cancerous lesions. The only significant difference in the clinical and pathological features of the two groups was a higher prevalence of associated multiple cancerous lesions in patients with the superficially spreading type.CONCLUSIONS:Superficially spreading carcinoma of the esophagus is often associated with multiple cancerous lesions. For endoscopists and esophageal surgeons, it is important to define the proximal extent of intraepithelial cancer and the presence of multiple cancerous lesions to perform curative resection.