Ryuji Yoshioka

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.

Pancreatic transection using a sharp hook-shaped ultrasonically activated scalpel

Background and aimsThe operative mortality and morbidity associated with pancreatic surgery has been decreasing; however, pancreatic fistula remains a major cause of a potentially fatal complication. Although different devices and techniques have been proposed to reduce of the postoperative pancreatic fistula, none has gained unanimous acceptance. We herein describe a new technique for pancreatic transection using a sharp hook-shaped ultrasonically activated scalpel (UAS).Materials and methodsBetween December 2004 and June 2006, 32 patients who had undergone pancreatectomies performed using the sharp hook-shaped UAS (Ethicon Endo-Surgery, Cincinnati, OH, USA) were studied.ResultsThe incidence of pancreatic fistula in these patients was 6.3% (2/32). Both cases underwent a distal pancreatectomy. No patient had systemic organ failure induced by postoperative pancreatic fistula, and conservative drainage management improved the pancreatic fistula. No pancreatic fistulas developed in patients who underwent pancreaticoduodenectomy with a duct-to-mucosa anastomosis pancreaticojejunostomy after pancreatic transection using the sharp hook-shaped UAS.ConclusionPancreatic transection using the sharp hook-shaped UAS is an easy and useful method that facilitates detection of the main pancreatic duct with minimal blood loss. It may contribute to lower morbidity and mortality after pancreatic resection.

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.

Is hepatic resection for recurrent or persistent hepatocellular carcinoma justified

BACKGROUND/AIMS The safety and effectiveness of hepatic resection for recurrent or refractory hepatocellular is not established, particularly in cases treated by non-surgical treatment. METHODOLOGY Surgical outcomes of 38 patients who underwent curative hepatic resection for recurrent or refractory disease after previous treatment were evaluated. Univariate and multivariate analyses were performed to identify prognostic predictors. RESULTS There were no postoperative deaths, morbidity occurred in 9 patients (prolonged ascites retention, 5; biliary fistula, 3; intraabdominal abscess, 1), and all of them were treated conservatively. Recurrence-free and overall 1, 3 and 5-year-survival rate was 54, 28 and 24%, and 78, 60 and 55%, respectively. Multivariate analysis revealed hepatitis B or C virus infection (HR=12.8; 95% CI=2.3-245.1), tumor size >5 cm (HR=5.9; 95% CI=5.9-25.6), and vasculo- biliary invasion (HR=5.2; 95% CI=1.4-21.0) were independent predictors of poor overall survival. Type of previous treatment did not influence prognosis. CONCLUSIONS Hepatic resection for recurrent or refractory hepatocellular carcinoma is safe and achieves long survival in selected patients.

Host MICA Polymorphism as a Potential Predictive Marker in Response to Chemotherapy for Colorectal Liver Metastases

Background: Understanding the genetic background of a tumor is important to better stratify patient prognosis and select optimal treatment. For colorectal liver metastases (CLM), however, clinically available biomarkers remain limited. Methods: After a comprehensive sequencing of 578 cancer-related genes in 10 patients exhibiting very good/poor responses to chemotherapy, the A5.1 variant of the MICA gene was selected as a potential biomarker for CLM. The clinical relevance of MICA A5.1 was then investigated in 58 patients who underwent CLM resection after chemotherapy. Results: The A5.1 variant was observed in 16 (27.6%) patients examined using direct DNA sequencing, and a very high concordance rate (56/58, 96.6%) for the MICA variant was confirmed between tumor tissues and normal liver parenchyma. A multivariate analysis of 38 patients with no history of treatment with anti-EGFR antibodies confirmed that MICA A5.1 was significantly correlated with an optimal CT morphologic response (OR 11.67; 95% CI 2.08–65.60; p = 0.005) and tended to be correlated with a tumor viability of < 20% after chemotherapy (OR 5.91; 95% CI 0.97–36.02; p = 0.054). MICA A5.1 was also associated with a decreased risk of progression after CLM resection. Conclusion: The MICA A5.1 polymorphism was associated with a better CT morphologic response to chemotherapy and a reduced risk of relapse after CLM resection. Given the high concordance rate in MICA variants between normal liver tissue and CLM, the genetic background of the host could be a new biomarker for CLM.

Impact of previous hepatectomy on short-term outcomes of repeat hepatectomy for liver tumors with a special concern of operative time.

BACKGROUND/AIMS Repeat hepatectomy is widely accepted as a treatment for primary or metastatic liver malignancy. However, it entails a longer operative time and is associated with additional operative risks. The goal of the present study was to evaluate the impact of previous hepatectomy on the short-term outcomes of repeat hepatectomy, especially in operative time. METHODOLOGY A retrospective review of prospectively collected data from patients who underwent primary hepatectomy (n=166) and repeat hepatectomy (n=65) in a single institution. RESULTS Operative time was significantly longer for repeat hepatectomy than for primary hepatectomy (284min vs. 250min, p=0.04). There were no significant differences between the two groups with respect to intraoperative blood loss, intraoperative blood transfusion, morbidity, mortality and length of hospital stay. Multivariate analysis demonstrated that third or subsequent hepatectomy and tumor location in the caudate lobe at the repeat hepatectomy significantly prolonged operative time. CONCLUSIONS Repeat hepatectomy has similar short-term outcomes to primary liver resection. However, repeat hepatectomy is a time-consuming operation, especially in patients with tumors in the caudate lobe or for those undergoing their third or subsequent hepatectomy.