Rintaro Koga

Pancreatoduodenectomy With Systematic Mesopancreas Dissection Using a Supracolic Anterior Artery-first Approach.

Objective: To describe the details of the surgical technique of pancreatoduodenectomy (PD) with systematic mesopancreas dissection (SMD-PD), using a supracolic anterior artery-first approach. Background: An artery-first approach in PD has been advocated in pancreatic cancer to judge resectability, clear the superior mesenteric artery margin from invasion, or reduce blood loss. However, the efficacy of an artery-first approach in mesopancreas dissection remains unclear. Methods: This study involved 162 consecutive patients who underwent PD with curative intent. The patients were divided into 82 SMD-PDs and 80 conventional PDs (CoPD) and then stratified further according to the dissection level, that is, level 1 was applied to 24 simple mesopancreas divisions for early inflow occlusion including 11 SMD-PDs, level 2 for 63 en bloc mesopancreas resections (26 SMD-PDs), and level 3 for 75 patients who underwent a hemicircumferential superior mesenteric artery plexus resection to keep the margin free from cancer invasion (45 SMD-PDs). The clinical and imaging results were collected to assess the feasibility and validity of SMD-PD with an artery-first approach. Results: Blood loss and operation duration were significantly less in the SMD-PD group than in the CoPD group among the total 162 patients. The imaging analysis showed that four fifths of pancreatic arterial branches came from the right dorsal aspect of the superior mesenteric artery and cancer abutment occurred exclusively from the same direction indicating the validity of an artery-first approach. Conclusions: SMD-PD using an SAA is feasible across PD cases, with acceptable short-term outcomes, and we propose this procedure as a promising option for PD.

Intrahepatic cholangiocarcinoma: analysis of 44 consecutive resected cases including 5 cases with repeat resections.

BACKGROUND Prognosis after resection for intrahepatic cholangiocarcinoma (ICC) remains unsatisfactory. There remains no effective therapy after recurrent ICC. OBJECTIVE The current study sought to evaluate risk factors associated with recurrent ICC and possible therapies after resection. METHOD A review of data from patients who underwent potentially curative resection for ICC was performed. RESULTS A total of 44 potentially curative resections were performed from 1995 to 2008. Mortality was 0% and morbidity was 35%. The 5-year overall and recurrence-free survival rates were 43% and 39%, respectively. Multivariate analysis identified the presence of multiple nodules and poor histologic grade as independent negative prognostic factors for overall and recurrent-free survival. Postoperative recurrence occurred in 25 patients (57%). Solitary recurrence occurred in 5 patients (liver, n = 4; lung, n = 1), all of who had undergone surgical resection. Three of the 5 patients survived for more than 5 years after 2 resections. CONCLUSION Prognosis after curative resection of solitary ICC appears favorable. In selected patients with sequential single hepatic or pulmonary recurrence, repeat resection may prolong survival.

Long-Term Survival in Patients with Locally Advanced Colon Cancer After En Bloc Pancreaticoduodenectomy and Colectomy

PurposeSurgical indications for colon cancer directly invading the pancreas head are controversial.MethodsBetween 1957 and 2007, a total of 12 patients (8 men) underwent pancreaticoduodenectomy combined with right hemicolectomy for colon cancer involving the pancreas head.ResultsMean age was 58 (range, 34–77) years. Fistula formation was observed in five patients (41 percent) preoperatively. Tumor involvement was duodenum only (n = 4), duodenum/pancreas (n = 3), stomach/pancreas (n = 1), duodenum/stomach (n = 2), duodenum/liver (n = 1), and pancreas only (n = 1). Only one postoperative death was encountered. Histologic examination showed malignant invasion to the pancreas head in nine cases (75 percent). Overall one-year, three-year and, five-year survival rates after surgery were 75, 66, and 55 percent, respectively. Five patients (41 percent) survived for more than ten 10 years.ConclusionsPancreaticoduodenectomy for advanced colon cancer invading the pancreas or duodenum provides favorable long-term survival.

Factors influencing infectious complications after pancreatoduodenectomy

Background/purposeRates of postoperative morbidity, particularly infectious complications, remain high after pancreatoduodenectomy.MethodsSubjects comprised 101 patients who had undergone pancreatoduodenectomy, analyzed according to presence or absence of infectious postoperative complications. Nineteen perioperative variables were analyzed to identify risk factors associated with postoperative infectious complications.ResultsPostoperative infectious complications occurred in 56 patients (55%); among them 29 had serious infectious morbidity, including bacteremia (13%), intra-abdominal infection (18%) and pneumonia (12%). One patient (1%) died of multiple organ failure subsequent to a severe septic attack. Only body mass index (BMI) differed significantly between patients with and without serious infection. Logistic regression analysis identified BMI >25 as an independent factor for occurrence of serious postoperative infectious complications. BMI >25 was a common risk factor for individual infection, including bacteremia, intra-abdominal infection, and pneumonia. As for the influence of BMI on perioperative parameters, the high BMI significantly affected the operation time. Meanwhile preoperative biliary drainage had no influence on overall and individual infectious morbidities.ConclusionsThis study demonstrates the need for careful postoperative monitoring in the patient with high BMI.

Simultaneous Resection of Colorectal Cancer and Synchronous Liver Metastases: Initial Experience of Laparoscopy for Colorectal Cancer Resection

Background/Aims:Although laparoscopy is accepted for treatment of colorectal cancer, there is no established consensus for its use when resection of synchronous liver metastases is performed simultaneously. The purpose of this study was to evaluate whether laparoscopic colorectal resection with simultaneous resection of synchronous liver metastases was technically feasible and whether it may be a therapeutic option. Methods: Ten patients underwent laparoscopic resection for primary colorectal cancer, combined with synchronous resection of liver metastases. Results: The primary tumor location was in the sigmoid colon in 3 patients and the rectum in 7. All laparoscopic colorectal resections were successful, with no conversion to open surgery. Simultaneously, there were 7 conventional open and 3 laparoscopy-assisted liver resections. The median total operating time was 446 (range 300–745) min, including 222 (range 152–313) min for colorectal resection. The median total estimated blood loss was 175 (range 30–1,200) ml, including 10 (range 0–550) ml for colorectal resection. There was no major morbidity, except 1 patient who developed decubitus. Conclusion: This preliminary report suggests that laparoscopic resection for sigmoid colon and rectal cancer, combined with synchronous resection of liver metastases, is a safe and feasible procedure in selected patients.

Improved Survival of Left-sided Pancreas Cancer after Surgery

OBJECTIVE Resective therapeutic strategy for left-sided pancreatic adenocarcinoma is open to debate. The post-resection outcomes and factors influencing post-resection survival for adenocarcinoma of the body and tail of the pancreas were analyzed to determine the effectiveness of surgery. METHODS A total of 73 patients with adenocarcinoma of the body or tail of the pancreas who underwent resection between 1994 and June 2007 were evaluated for overall survival. RESULTS Multiple malignancies were present in 34 of 73 patients (47%). Overall 1-, 3- and 5-year survival rates after surgery were 79%, 34%, and 30%, respectively. Presence of symptoms, multiple cancers and level of preoperative tumor marker did not influence post-resection survival. As for tumor characteristics, tumor size, histological tumor differentiation, retroperitoneal invasion, status of residual tumor and UICC staging represented significant prognostic indicators by univariate analysis. Gemcitabine, when administered as an adjuvant settings, strongly worked for improving post-resection outcome (5-year survival rate = 51%). Factors shown to have independent prognostic significance on multivariate analysis were tumor size (<3 vs. >or=3 cm), status of residual tumor (R0 vs. R1, 2), and postoperative administration of gemcitabine. CONCLUSIONS Appropriate patient selection and accurate surgical technique with postoperative adjuvant therapy could benefit survival of patients with carcinoma of the pancreas body and tail.

Sinistral portal hypertension after pancreaticoduodenectomy with splenic vein ligation.

Splenic vein ligation may result in sinistral (left‐sided) portal hypertension and gastrointestinal haemorrhage. The aim of this study was to analyse the pathogenesis of sinistral portal hypertension following splenic vein ligation in pancreaticoduodenectomy.

Surgical treatment for metastatic malignancies. Nonanatomical resection of liver metastasis: indications and outcomes.

Surgical resection represents the only radical treatment for liver metastases from colorectal cancer, and has been investigated at many centers. Prospective comparative studies are needed to more accurately verify the advantages of resection. However, now that surgical resection is considered to have a certain survival benefit and other treatment modalities show a low likelihood of cure, the studies that are actually being conducted should be those comparing surgical resection with non-surgical treatment in patients for whom surgical resection is of some limited use. Surgeons express differing opinions regarding the selection of resection procedures (anatomical hepatectomy vs nonanatomical limited hepatectomy) and the extent of surgical margins. The present report discusses the findings of a literature review focusing on these contentious issues.

Safety and efficacy of hepatic vein reconstruction for colorectal liver metastases

BACKGROUND Colorectal liver metastases with hepatic vein (HV) involvement may require combined resection of the liver and HV. However, the short- and long-term outcomes of such a procedure remain unclear. METHODS We reviewed 16 cases of liver resection with major HV resection and reconstruction. RESULTS The patients had a median age of 58.5 years (range, 50-74 y). In total, 18 HVs were reconstructed using a customized great saphenous vein graft (n = 10), direct anastomosis (n = 1), external iliac vein (n = 2), portal vein (n = 1), umbilical vein patch graft (n = 3), or ovarian vein patch graft (n = 1). There was no hospital mortality, and the morbidity rate was 50%. With a median follow-up period of 30 months (range, 4-89 mo), 3 patients died of tumor recurrence and 13 were alive with (n = 6) and without (n = 7) disease. Cumulative 1-, 3-, and 5-year survival rates were 93%, 76%, and 76%, respectively. CONCLUSIONS HV resection and reconstruction combined with liver resection can be performed safely with reasonable long-term results.

Preoperative transarterial chemoembolization for hepatocellular carcinoma.

BACKGROUND/AIMS The effects of transarterial chemoembolization (TACE) prior to hepatectomy for patients with hepatocellular carcinoma (HCC) are controversial. METHODOLOGY Clinicopathological profiles and prognosis were compared between patients who underwent hepatic resection following preoperative TACE (Group A, 69 patients) or only resection (Group B, 158 patients). Univariate and multivariate analyses were used to evaluate whether TACE influenced patient prognosis. RESULTS Profiles of Group A were comparable with those of Group B except for younger age, higher frequency of major hepatectomy, higher incidence of positive surgical margin, vascular invasion and poorly differentiated HCC. Overall survival was significantly worse in Group A than in Group B (5-year survival rate; 29% vs. 69%; p<0.001). A subset of patients in Group A with complete tumor necrosis by TACE showed comparable survival with Group B. Multivariate analysis revealed that preoperative TACE (hazard ratio (HR)=4.3; 95% confidential interval (CI), 2.8-6.6), non-anatomic resection (HR=1.6; 95% CI, 1.1-2.4), blood loss >1L (HR=1.8; 95% CI=1.1-2.8) and vascular invasion (HR=2.3; 95% CI=1.4-3.6) were independent predictors of poor survival. Preoperative TACE was also an independent predictor of extrahepatic metastases (odds ratio, 2.8; 95% CI=1.1-7.1). CONCLUSIONS Preoperative TACE should not be routinely applied for HCC.