Ryo Ashida

The optimal cut-off value of the preoperative prognostic nutritional index for the survival differs according to the TNM stage in hepatocellular carcinoma

PurposeTo establish the optimal cut-off value of the preoperative prognostic nutritional index (PNI) for prognosis according to the Tumor Node Metastasis (TNM) stage of hepatocellular carcinoma (HCC) after curative resection.MethodsThis retrospective study reviewed the records of 375 patients. The optimal cut-off value of the PNI was established according to the TNM stage, and overall survival was compared between the low and high PNI groups.ResultsThe optimal cut-off value of the PNI decreased with increasing TNM stage, with 52, 47, and 43 patients having stage I, II, and III HCC, respectively. A low preoperative PNI predicted a poorer overall survival than did a high PNI for stage I (P < 0.001) and II (P = 0.002), but not stage III disease (P = 0.052). Multivariate analysis revealed that the preoperative PNI was an independent predictor of overall survival for stage I and II HCC (hazard ratios: 6.96 and 3.57, P = 0.001 and P = 0.001, respectively).ConclusionsThe findings of this study show that the optimal cut-off value for the PNI for prognosis differs among the TNM stages and that the preoperative PNI is a favorable prognostic factor for stage I HCC.

Is combined pancreatoduodenectomy for advanced gallbladder cancer justified

BACKGROUND The clinical impact of combined pancreatoduodenectomy (PD) for advanced gallbladder cancer remains unclear. METHODS A total of 96 patients who underwent resection for stage II, III, or IV gallbladder cancer were enrolled. Patients with lower bile duct involvement, pancreatic or duodenal infiltration, or peripancreatic lymph node metastasis were considered candidates for combined PD. The operative outcomes were compared between the patients treated with PD (PD group, n = 21) and those treated without PD (non-PD group, n = 75), and between those treated with major hepatopancreatoduodenectomy (major HPD group, n = 9) and those treated with major hepatectomy (major hepatectomy group, n = 20). RESULTS Overall morbidity in the PD group was greater than that in the non-PD group (81% vs 23%, P < .001), whereas the overall survival (OS) was comparable between the groups (5-year OS; 39.8% vs 46.7%, P = .96). There was no in-hospital mortality in the PD group. A serum albumin <3.0 g/dL (P = .004) and tumor size ≥ 9.0 cm (P = .029) were associated independently with a poor prognosis in the PD group. Overall morbidity in the major HPD group was greater than that in the major hepatectomy group (89% vs 40%, P = .014), whereas the OS was comparable between the groups (5-year OS; 34.6% vs 21.1%, P = .57), and the OS of major HPD group was better than that of unresectable group (n = 18, P = .017). CONCLUSION Combined PD, including major HPD, is beneficial for selected patients of advanced gallbladder cancer; however, the indications should be carefully evaluated because of greater morbidity rates.

Perioperative Computed Tomography Assessments of the Pancreas Predict Nonalcoholic Fatty Liver Disease After Pancreaticoduodenectomy

AbstractNonalcoholic fatty liver disease (NAFLD) after pancreaticoduodenectomy (PD) has become a clinically important issue. Although pancreatic exocrine insufficiency has been reported to be a main cause of NAFLD after PD, a clinically practical examination to assess the pancreatic exocrine function has not been established. The aim of this study was to evaluate risk factors for NAFLD after PD with a focus on perioperative computed tomography (CT) assessments of the pancreas.A retrospective review of 245 patients followed for more than 6 months after PD was conducted. We evaluated several pancreatic CT parameters, including the pancreatic parenchymal thickness, pancreatic duct-to-parenchymal ratio, pancreatic attenuation, and remnant pancreatic volume (RPV) on pre- and/or postoperative CT around 6 months after surgery. The variables, including the pancreatic CT parameters, were compared between the groups with and without NAFLD after PD.The incidence of NAFLD after PD was 19.2%. A multivariate analysis identified 5 independent risk factors for NAFLD after PD: a female gender (odds ratio [OR] 5.66, P < 0.001), RPV < 12 mL (OR 4.73, P = 0.001), preoperative pancreatic attenuation of <30 Hounsfield units (OR 4.50, P = 0.002), dissection of the right-sided nerve plexus around the superior mesenteric artery (OR 3.02, P = 0.017) and a preoperative serum carbohydrate antigen 19–9 level of ≥70 U/mL (OR 2.58, P = 0.029).Our results showed that 2 pancreatic CT parameters, the degree of preoperative pancreatic attenuation and RPV, significantly influence the development of NAFLD after PD. Perioperative CT assessments of the pancreas may be helpful for predicting NAFLD after PD.

Gangliocytic Paraganglioma of the Minor Papilla of the Duodenum

A duodenal polyp was found during a health check of a 71-year-old asymptomatic man. Duodenoscopy demonstrated a pedunculated, smooth-surfaced tumor of 18 mm in size, protruding from the minor papilla. Endoscopic ultrasonography demonstrated a homogeneously low-echoic submucosal tumor. Enhanced computed tomography and magnetic resonance imaging demonstrated a well-enhanced duodenal tumor without obvious metastasis. A tumor biopsy revealed a well-differentiated neuroendocrine tumor, and laparotomic transduodenal polypectomy with regional lymph node dissection was performed. The histology of the surgical specimen revealed gangliocytic paraganglioma consisting of three cell types: endocrine, ganglion, and spindle cells. There has been no recurrence in >5 years after surgery.

Pancreaticoduodenectomy with hepatic arterial revascularization for pancreatic head cancer with stenosis of the celiac axis due to compression by the median arcuate ligament: a case report

Abstract A 71-year-old woman presented to our hospital because pancreatic head cancer was suspected on a medical checkup. Computed tomography showed a 30 mm low-density lesion in the pancreatic head, and the stenosis of the celiac axis (CA) due to the median arcuate ligament (MAL) compression. We made a preoperative diagnosis of pancreatic head cancer and performed laparotomy. Transection of the MAL failed to restore adequate hepatic arterial flow, necessitating arterial revascularization, which was achieved by end-to-end anastomosis between the gastroduodenal artery and the middle colic artery. After reconstruction, Doppler ultrasonography showed improved hepatic arterial signal. The patient was discharged 16 days after surgery with no complications. When planning pancreaticoduodenectomy (PD) for such patients with CA stenosis due to MAL compression, surgeons should simulate a situation of insufficient hepatic arterial flow after division of the MAL, and prepare for reconstruction of the hepatic artery during PD.

Combined Antrectomy Reduces the Incidence of Delayed Gastric Emptying after Pancreatoduodenectomy

Background: There are a few reports that compare the rate of postoperative complications between subtotal stomach-preserving pancreatoduodenectomy (SSPPD) and antrectomy-combined pancreatoduodenectomy (ACPD), especially with respect to delayed gastric emptying (DGE) after pancreatoduodenectomy (PD). Methods: From 2002 to 2013, 628 patients who underwent SSPPD (n = 78) or ACPD (n = 550) were enrolled in this study. The rate of DGE and the nutritional status were compared between patients receiving ACPD and SSPPD. Results: The overall morbidity rate (p = 0.830) was comparable between both groups; however, the incidence of DGE grade B or C was significantly higher in the SSPPD group than that in the ACPD group (16 vs. 7%, p = 0.007). A multivariate analysis identified SSPPD rather than ACPD (p = 0.007) and portal vein resection and reconstruction (p = 0.028) to be independent risk factors for DGE grade B or C. The changes in the body weight and nutritional parameters 3, 6, and 12 months after surgery were comparable between 2 groups. Conclusions: SSPPD and not ACPD was an independent risk factor for grade B or C DGE, but the postoperative nutritional status was comparable between the 2 groups based on the limited nutritional data. Combined resection of antrum will help reduce the risk of DGE after PD.

Combined resection of the transpancreatic common hepatic artery preserving the gastric arterial arcade without arterial reconstruction in hepatopancreatoduodenectomy: a case report

BackgroundSurgeons sometimes must plan pancreatoduodenectomy (PD) for patients with a variant common hepatic artery (CHA) branching from the superior mesenteric artery (SMA) penetrating the pancreatic parenchyma, known as a transpancreatic CHA (tp-CHA).Case presentationA 67-year-old man was admitted to our hospital because of liver dysfunction. A duodenal tumor was identified by gastrointestinal endoscopy, and a biopsy revealed a neuroendocrine tumor. Computed tomography showed multiple metastases in the left three sections of the liver. As an anatomical variant, the CHA branched from the SMA and passed through the parenchyma of the pancreatic head, and all hepatic arteries branched from the CHA. Furthermore, the arcade between the left and right gastric artery (RGA) was detected, and the RGA branched from the root of the left hepatic artery. PD and left trisectionectomy of the liver were performed. The tp-CHA was resected with the pancreatic head, and the gastric arterial arcade was preserved to maintain the right posterior hepatic arterial flow. Postoperatively, there were no signs of hepatic ischemia.ConclusionsWhen planning PD, including hepatopancreatoduodenectomy, for patients with a tp-CHA, surgeons should simulate various situations for maintaining the hepatic arterial flow. The preservation of the gastric arterial arcade is an option for maintaining the hepatic arterial flow to avoid arterial reconstruction.

Bile duct angulation and tumor vascularity are useful radiographic features for differentiating pancreatic head cancer and intrapancreatic bile duct cancer

Background and purposeTo perform radical resection without leaving residual cancer, surgeons must distinguish between pancreatic head cancer (PHC) and intrapancreatic bile duct cancer (IPBDC) preoperatively. The aim of this study was to establish the points of difference between these two cancers, especially on preoperative multi-detector computed tomography (MDCT) images.MethodsThe subjects of this study were 28 patients with PHC and proven bile duct invasion who underwent pancreatoduodenectomy (PHC group) and 22 patients with IPBDC and upstream bile duct dilation (IPBDC group). We compared the preoperative clinical and radiographic features, including the bile duct angle, calculated on coronal images of MDCT, and the vascularity of the tumor.ResultsThe optimal cut-off values for the bile duct angle, the CT value ratio of the tumor (late arterial phase/non-enhanced), and the main pancreatic duct (MPD) ratio (diameter of MPD/diameter of parenchyma) were 110°, 3.0, and 0.2, respectively. Multivariate analysis revealed that a bile duct angle < 110°, a CT value ratio of the tumor < 3, and an MPD ratio ≥ 0.2 were independently associated with PHC.ConclusionsA bile duct angle and CT value reflecting the vascularity of the tumor might be useful radiographic features for differentiating PHC and IPBDC, in addition to MPD dilatation.

A predictive scoring system for insufficient liver hypertrophy after preoperative portal vein embolization

Background: The factors which affect hypertrophy of the future liver remnant after portal vein embolization remain unclear. The aim of this study was to clarify the clinical factors affecting the hypertrophy rate after portal vein embolization and to develop a scoring system predicting insufficient liver hypertrophy. Methods: The cases of a total of 152 patients who underwent portal vein embolization of the right portal branch between 2006 and 2016 were reviewed retrospectively. The score to predict insufficient (<25%) hypertrophy was established based on logistic regression analyses of the clinical parameters before portal vein embolization. Results: After portal vein embolization, the future liver remnant volume, expressed as the median (range), significantly increased from 364 (151–801) mL, 33% (18%–54%), to 451 (242–866) mL, 42% (26%–65%). The median hypertrophy rate was 24% (−5% to 96%). A preoperative predictive scoring system for insufficient liver hypertrophy was constructed using the following 3 factors: an initial future liver remnant volume ≥35% (2 points), alkaline phosphatase ≥450 IU/dL (1 point), and cholinesterase <220 mg/dL (1 point). The constructed scoring system indicated the proportion of patients with insufficient liver hypertrophy (<25%) to be 6 out of 42 (14%) in the low‐score group (0 points), 44 out of 77 (57%) in the medium‐score group (1–2 points), and 30 out of 33 (91%) in the high‐score group (3–4 points). The hypertrophy rate of future liver remnant was different among the 3 groups (low‐score group, 38.9% [−2.4% to 81.4%]; medium‐score group, 22.7% [−5.1% to 95.5%]; high‐score group, 18.2% [2.4%–30.7%]) (P < .001). Conclusion: The constructed scoring system was able to stratify patients before portal vein embolization according to the possibility of developing insufficient liver hypertrophy.

Third-generation cephalosporin for antimicrobial prophylaxis in pancreatoduodenectomy in patients with internal preoperative biliary drainage

Background: The aim of the present study was to investigate whether the incidence of surgical site infection after pancreatoduodenectomy decreased after changing the prophylactic antibiotic to a third‐generation cephalosporin in patients with unknown preoperative bile culture results after biliary drainage. Methods: In a retrospective study of 138 pancreatoduodenectomy patients who underwent endoscopic biliary stenting and for whom recent preoperative bile culture results were unavailable, cefazolin sodium hydrate was administered as perioperative prophylactic antibiotic therapy from 2010 to 2014 (n = 69); whereas ceftriaxone was administered from 2014 to 2017 (n = 69) based on the results of institutional culture surveillance. The incidence of surgical site infection was compared between the two groups and the risk factor of surgical site infection was also evaluated. Results: The incidence of overall surgical site infection in the ceftriaxone group was significantly lower than that in the cefazolin sodium hydrate group for both Clavien‐Dindo grade ≥II (28% versus 52%, P = .005) and Clavien‐Dindo grade ≥IIIa (20% vs 41%, P = .016). A multivariate analysis revealed that the prophylactic administration of cefazolin sodium hydrate was associated with a higher incidence of overall surgical site infection in both Clavien‐Dindo grade ≥II and Clavien‐Dindo grade ≥IIIa (odds ratio 2.56, P = .019; odds ratio 3.03, P = .020, respectively). In the cefazolin sodium hydrate group, most of the patients with positive perioperative cultures had Enterobacteriaceae, which were intrinsically resistant to cefazolin sodium hydrate, and most were susceptible to ceftriaxone. Conclusion: The prophylactic administration of third‐generation cephalosporin reduced the incidence of surgical site infection after pancreatoduodenectomy in patients who underwent preoperative endoscopic biliary stenting.