Reiko Tanabe

Follow-up study after resection of intraductal papillary mucinous neoplasm of the pancreas; special references to the multifocal lesions and development of ductal carcinoma in the remnant pancreas

BACKGROUND Frequency and characteristics of metachronous occurrence of multifocal intraductal papillary mucinous neoplasms (IPMNs) or distinct pancreatic ductal adenocarcinomas (PDACs) in the remnant pancreas during follow-up evaluation after pancreatectomy for IPMNs have not been well known. The aim of this study was to investigate the outcomes after resection of IPMNs, especially focusing on the metachronous occurrence of multifocal IPMNs and distinct PDACs. METHODS Medical records of 172 patients who underwent resection of IPMNs were reviewed retrospectively, and the data regarding the occurrence of metachronous IPMNs or PDACs in the remnant pancreas during a mean postoperative follow-up period of 64 months were collected. RESULTS The incidence including synchronous and metachronous multifocal occurrence of IPMNs was 20% (34 of 172), and that of distinct PDACs was 9.9% (17 of 172). Ten metachronous IPMNs developed in the remnant pancreas after a mean time of 23 postoperative months (range, 12-84 mo), and 2 with main duct IPMNs (both were carcinoma in situ) required remnant pancreatectomy. Six distinct PDACs developed in the remnant pancreas after a mean time of 84 postoperative months (range, 12-150 mo). Four of them were found to have a tumor with a size of less than 2 cm, whereas the remaining 2 PDACs were found to be unresectable more than 10 years after resection of IPMNs. CONCLUSIONS Intense long-term follow-up evaluation is necessary for the early detection of metachronous occurrence of distinct PDACs as well as malignant IPMNs after resection of IPMNs.

Manometric evidence of earlier recovery of fasting gastric motility after antecolic duodenojejunostomy than after retrocolic duodenojejunostomy following PPPD.

BACKGROUNDS/AIMS Gastric stasis is a unique complication of pylorus-preserving pancreatoduodenectomy (PPPD). Although some studies reported less prevalence of gastric stasis after antecolic duodenojejunostomy, there have been no reports on detailed comparison of gastric motility after antecolic vs. retrocolic duodenojejunostomy after PPPD. METHODOLOGY Thirty-six patients underwent PPPD with the modified Child reconstruction. Retrocolic duodenojejunostomy was utilized in initial 13 patients (retrocolic group). For comparison, antecolic duodenojejunostomy was employed in subsequent 23 patients (antecolic group). A manometric tube assembly was inserted into the gastric antrum and jejunum during PPPD. Gastrointestinal motility was recorded for 3 hours a day, starting on 6 to 14 days after surgery and repeated at a weekly interval until the first appearance of phase 3 gastric motility. Various clinical parameters were also assessed. RESULTS Recovery of gastric phase 3 was identified in 19 of 36 patients. Recovery of phase 3 was faster in antecolic group than in retrocolic group (p<0.01). The amount of the gastric juice output during 14 postoperative days was larger in retrocolic group than in antecolic group (p<0.01). Resumption of water intake and food intake was earlier and the length of intravenous hyperalimentation and hospital stay was shorter in antecolic group than in retrocolic group (p<0.05). CONCLUSIONS Antecolic duodenojejunostomy contributes to early recovery of gastric phase 3 motility in patients after PPPD, leading to prevention of early gastric stasis.

Prevention of iatrogenic bile duct injuries in difficult laparoscopic cholecystectomies: is the naso‐biliary drain the answer?

BACKGROUND Prevention of iatrogenic injuries is of paramount importance in difficult laparoscopic cholecystectomies (LC). The objective of this study was to analyze the effectiveness of cholangiography using a pre-inserted endoscopic naso-biliary drain (ENBD) for navigation during difficult cholecystectomies. METHODS The study design was a retrospective case analysis. In 508 patients who underwent LC in a tertiary referral university hospital from 1996 through 2007, difficult cholecystectomy was anticipated in 26 patients due to possibly aberrant biliary anatomy (four patients), unclear cystic duct anatomy during magnetic resonance cholangiopancreatography (MRCP) and/or endoscopic retrograde cholangiopancreatography (ERCP) (three patients), and acute cholecystitis (19 patients). An ENBD was inserted during ERCP prior to LC for cholangiography (ENBDC) to facilitate safe dissection during LC. Prevalence of biliary complications was assessed as the main outcome measurement. RESULTS The majority (68%) of the patients who underwent ENBDC had complicated cholecystitis. Advanced technical expertise was not required for insertion of an ENBD. In retrospect, ENBDC was useful in prevention of a possible catastrophe in 69% of cases. Open conversion was necessary in five patients and biliary complications occurred in five patients only in the non-ENBD group. There were no procedure-related complications. One limitation of the study was that it was not randomized and there was no comparison with patients without ENBDC. CONCLUSIONS ENBDC is a useful and safe tool in the prevention of iatrogenic bile duct injuries in LC.

Treatment of arteriovenous shunts after renal transplantation

PurposeImmunosuppressive drugs have improved the results of renal transplantation dramatically in recent years; however, there is still no consensus on the treatment of arteriovenous (A-V) shunts after successful transplantation. We evaluated the treatment of A-V shunts after transplantation.MethodsWe reviewed all patients who underwent shunt closure at our hospital between 2005 and 2007 assessing surgical methods, operative time, blood loss, and complications.ResultsFifty-two patients underwent shunt closure, as a simple transection in 5 patients, resection of the anastomotic site in 16, resection and reconstruction of the artery in 26, and graftectomy in 5. Graftectomy was associated with copious blood loss and a long operative time. The most frequent complication was phlebitis, but there were no nerve complications.ConclusionsAn A-V shunt after renal transplantation may result in an aneurysm, severe venous dilatation, pain, bloating of the arm, infection, and cardiac problems. Thus, after successful transplantation, shunt closure should be performed to prevent these complications and to improve quality of life.