Shin Ishihara

Biliary tract cancer treatment : 5,584 results from the Biliary Tract Cancer Statistics Registry from 1998 to 2004 in Japan

BACKGROUND/PURPOSE The results from the Japanese Biliary Tract Cancer Statistics Registry from 1988 to 1998 were reported in 2002. In the present study, we report here selectively summarized data as an overview of the 2006 follow-up survey of the registered cases from 1998 to 2004 for information bearing on problems with the treatment of cancer of the biliary tract. METHODS A total of 5,584 patients were registered from 1998 to 2004. The site of cancer was the bile duct in 2,732 patients, the gallbladder in 2,067, and the papilla of Vater in 785. Those cases were analyzed with regard to patient survival according to the extent of tumor invasion (pT), the extent of lymph node metastasis (pN) and the stage. RESULTS The five-year survival rate after surgical resection was 33.1% for bile duct cancer, 41.6% for gallbladder cancer, and 52.8% for cancer of the papilla of Vater. For hilar or superior bile duct cancer, the 5-year survival rate was lower with an increase in the pT, pN and f stage, except pT3 vs. pT4, pN1 vs. pN2 and stage III vs. stage IVa. For middle or distal bile duct cancer, the 5-year survival rate was lower with increase in pT, pN and f stage, except pT2 vs. pT3, pN2 vs. pN3, stage II vs. stage III and stage III vs. stage IVa. For gallbladder cancer, the 5-year survival rate was lower with increase in pT, pN and f stage. For cancer of the papilla of Vater, the 5-year survival rate was lower with increase in pT, pN and f stage, except pT1 vs. pT2, pN1 vs. pN2, and stage III vs. stage IVa. CONCLUSIONS In the present study, the outcomes of surgical treatment were better than that of the previous report from Japan and foreign countries. The pT, pN and stage of gallbladder cancer are well defined. However, there were no significant differences in some groups of those of bile duct cancer and cancer of the papilla of Vater.

Pancreaticobiliary maljunction and carcinogenesis to biliary and pancreatic malignancy

BackgroundIt is widely accepted that congenital choledochal cyst is associated with pancreaticobiliary maljunction (PBM). But, PBM is an independent disease entity from choledochal cyst. PBM is synonymous with “abnormal junction of the pancreaticobiliary ductal system”, “anomalous arrangement of pancreaticobiliary ducts”, “anomalous union of bilio-pancreatic ducts”, etc. Cases with PBM not associated with biliary duct dilatation are often found, and these cases are frequently complicated gallbladder cancer. The Japanese Study Group of Pancreaticobiliary Maljunction was started in 1983, and defined diagnostic criteria and nationwide registration system of PBM cases was started. PBM is defined as a union of the pancreatic and biliary ducts which is located outside the duodenal wall. Bile and pancreatic juice reflux and regurgitate mutually.Biliary carcinogenesisThe most bothersome problem is biliary carcinogenesis. Gallbladder cancers arise in 14.8% and bile duct cancers arise in 4.9%. The incidence of the gallbladder carcinoma of PBM without bile duct dilatation is 36.1%. Many investigators have tried to clarify the carcinogenic process, from various aspects. The biliary epithelia are injured by harmful substances, and in the course of repair, multiple alterations of oncogenes and tumor suppressor genes are followed, and they lead to carcinoma through multistage interaction. In the biliary epithelia of PBM, incidence and degree of hyperplasia are characteristic. K-ras gene mutations are observed in the cancerous as well as noncancerous lesions of biliary tract of PBM patients. Mutations of p53 gene and overexpression of p53 protein are also found in the cancerous and noncancerous lesions. These changes are called “hyperplasia–carcinoma sequence”.TreatmentTotal excision of the extrahepatic bile duct with gallbladder followed by hepaticojejunostomy, Roux-en-Y, or end-to-side hepaticoduodenostomy are treatment of choice, even for cases with not dilated bile duct, because the incidence of cancer in the nondilated bile duct is not negligible, and genetic changes are seen in a nondilated bile duct.

Multislice CT study of pancreatic head arterial dominance.

BACKGROUND/PURPOSE When a pancreatoduodenectomy is to be conducted, preoperative understanding of the vascular anatomy of the pancreatic head is important in order to reduce intraoperative bleeding. Using multislice computed tomography (MS-CT), we investigated the depiction rate and branching of the inferior pancreaticoduodenal artery (IPDA) and dorsal pancreatic artery (DPA), afferent arteries to the pancreatic head. METHODS In 109 patients (68 with pancreatic cancer, 21 with biliary tract cancer, 15 with intraductal papillary mucinous tumor of the pancreas, and 5 others), images were taken, using 64-row MS-CT, in the early and late arterial phases. RESULTS The depiction rates were 98.2% for the IPDA and 96.3% for the DPA. Branching of the IPDA was categorized into three types: a type in which the IPDA formed a common vessel with the first jejunal branch (72.0%), a type in which the IPDA branched directly from the superior mesenteric artery (18.7%), and a type in which the anterior inferior pancreaticoduodenal artery (AIPDA) and posterior inferior pancreaticoduodenal artery (PIPDA) branched separately (9.3%). DPA branching was categorized into five types, in which the DPA branched from the splenic artery (40.0%), from the common hepatic artery (25.7%), from the superior mesenteric artery (20.0%), and from the celiac artery (8.6%), and a type in which the DPA branching did not follow any of the above patterns (5.7%). CONCLUSIONS MS-CT images of vascular architecture enable evaluation from any angle, which is not possible with conventional angiography, making MS-CT a useful diagnostic imaging technique for understanding the vascular anatomy of the pancreatic head prior to conducting pancreatoduodenectomy for diseases of the pancreatic head region.

Flowcharts for the management of biliary tract and ampullary carcinomas

No strategies for the diagnosis and treatment of biliary tract carcinoma have been clearly described. We developed flowcharts for the diagnosis and treatment of biliary tract carcinoma on the basis of the best clinical evidence. Risk factors for bile duct carcinoma are a dilated type of pancreaticobiliary maljunction (PBM) and primary sclerosing cholangitis. A nondilated type of PBM is a risk factor for gallbladder carcinoma. Symptoms that may indicate biliary tract carcinoma are jaundice and pain in the upper right area of the abdomen. The first step of diagnosis is to carry out blood biochemistry tests and ultrasonography (US) of the abdomen. The second step of diagnosis is to find the local extension of the carcinoma by means of computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP). Because resection is the only way to completely cure biliary tract carcinoma, the indications for resection are determined first. In patients with resectable disease, the indications for biliary drainage or portal vein embolization (PVE) are checked. In those with nonresectable disease, biliary stenting, chemotherapy, radiotherapy, and/or best supportive care is selected.

Status of Surgical Treatment of Biliary Tract Cancer

Complete surgical resection of biliary tract carcinoma remains the best treatment. The Japanese Society of Biliary Surgery has organized a registry project and established a classification of biliary tract carcinoma. We report here the status of biliary surgery in Japan. For hilar bile duct carcinoma, major hepatectomy is needed to increase the resection rate, and total caudate lobectomy is required for curative resection. The 5-year survival rate was 39.1%. Middle and distal bile duct carcinomas were treated with pancreatoduodenectomy (PD) or pylorus-preserving PD (PPPD) or bile duct resection alone. The 5-year survival rate was 44.0%. The treatment of gallbladder carcinoma with pT1 lesions is cholecystectomy. The treatment of pT2 lesions is extended cholecystectomy or various hepatectomy with or without extrahepatic bile duct resection along with lymphadenectomy. Treatment of pT3 and pT4 lesions includes hepatectomy with or without bile duct resection, combined with vascular resection, extended lymphadenectomy, and autonomic nerve dissection. Several groups in Japan have performed hepatopancreatoduodenectomy. The 5-year survival rate of pT1, pT2, pT3, and pT4 were 93.7, 65.1, 27.3, and 13.8%. PD or PPPD is the standard operation for carcinoma of the papilla of Vater. The 5-year survival rate was 57.5%.

Gallbladder bed resection or hepatectomy of segments 4a and 5 for pT2 gallbladder carcinoma: analysis of Japanese registration cases by the study group for biliary surgery of the Japanese Society of Hepato-Biliary-Pancreatic Surgery

PurposeHepatectomy of segments 4a and 5 (S4a+5) is the recommended treatment for pT2 gallbladder cancer. However, gallbladder bed resection is also occasionally used. Using nationwide data from the Japanese Biliary Tract Cancer Registry and a questionnaire survey, we retrospectively compared these 2 methods of treatment.MethodThe study involved 85 patients with pT2, pN0 gallbladder cancer (55 treated with gallbladder bed resection, and 30, with S4a+5 hepatectomy). The prognosis and mode of tumor recurrence following treatment were analyzed retrospectively, with overall survival as the endpoint.ResultsThe 5-year survival rate did not differ significantly between the 2 groups. Univariate analysis showed that bile duct resection and perineural tumor invasion were significant prognostic factors, but the extent of hepatectomy, location of the major intramural tumor, regional lymph node excision, and histological type were not. Multivariate analysis identified perineural tumor invasion as a significant prognostic factor. Recurrence occurred most frequently in both lobes than S4a+5 of the liver following gallbladder bed resection.ConclusionIn the present study of cases of Japanese Biliary Tract Cancer Registry, it was not possible to conclude that S4a+5 hepatectomy was superior to gallbladder bed resection.

Robot-assisted laparoscopic pancreatic surgery.

BackgroundIn the field of gastroenterological surgery, laparoscopic surgery has advanced remarkably, and now accounts for most gastrointestinal operations. This paper outlines the current status of and future perspectives on robot-assisted laparoscopic pancreatectomy.MethodsA review of the literature and authors’ experience was undertaken.ResultsThe da Vinci Surgical System is a robot for assisting laparoscopy and is safer than conventional endoscopes, thanks to the 3-dimensional hi-vision images it yields, high articular function with the ability to perform 7 types of gripping, scaling function enabling 2:1, 3:1, and 5:1 adjustment of surgeon hand motion and forceps motions, a filtering function removing shaking of the surgeon’s hand, and visual magnification. By virtue of these functions, this system is expected to be particularly useful for patients requiring delicate operative manipulation.ConclusionsIssues of importance remaining in robot-assisted laparoscopic pancreatectomy include its time of operation, which is longer than that of open surgery, and the extra time needed for application of the da Vinci compared with ordinary laparoscopic surgery. These issues may be resolved through accumulation of experience and modifications of the procedure. Robot-assisted laparoscopic pancreatectomy appears likely to become a standard procedure in the near future.

Biliary tract cancer registry in Japan from 2008 to 2013.

The present study analyzed biliary tract cancer patients registered from 2008 to 2013 in Japan and evaluated the outcomes of biliary tract cancer.

Estimation of fat absorption with the 13C-trioctanoin breath test after pancreatoduodenectomy or pancreatic head resection.

Abstract. The aim of this study was to determine if fat absorption is better after pylorus-preserving pancreatoduodenectomy (PPPD) or duodenum-preserving pancreatic head resection (DPPHR) compared with that following pancreatoduodenectomy with gastrectomy (SPD), provided the patients have similar pancreatic exocrine function. Fat absorption was studied using the 13 C-trioctanoin breath test in patients who were grouped according to the degree of fibrosis of the pancreatic remnant. The latter was judged by histologically measuring the fibrosis in a transectional wedge of resected pancreas. We evaluated 11 SPD cases, 25 PPPD cases, and 9 DPPHR cases. The 13 C excretion rates and cumulative excretion values following DPPHR or PPPD were significantly better than those following SPD. The 13 C excretion rates and cumulative values for the patients with > 30% fibrosis of the pancreas were lower than those in patients with < 30% pancreatic fibrosis, regardless of the surgical procedure. The cumulative value in the SPD group, however, was lower than that in the PPPD or DPPHR patients with < 30% pancreatic fibrosis. The results suggested that fat absorption following PPPD or DPPHR is superior to that after SPD in patients with the same fibrotic area of the pancreatic remnant and depends on the degree of fibrosis in the pancreatic remnant.

Intraductal papillary adenocarcinoma with mucin hypersecretion and coexistent invasive ductal carcinoma of the pancreas with apparent topographic separation

We report a 66-year-old man who had a cystic intraductal papillary adenocarcinoma containing a papillary adenoma, in the head of the pancreas and a coexistent invasive, well differentiated solid tubular adenocarcinoma in the tail of the pancreas. He was hospitalized with acute epigastralgia. Computed tomography demonstrated a multilocular cystic mass in the head of the pancreas and a solid tumor in the tail. Endoscopic retrograde pancreatography showed mucin secretion from an enlarged papilla of Vater, marked dilatation of the main pancreatic duct in the head and body, cystic dilatation of the uncinate branch, and irregular narrowing of the main pancreatic duct in the tail. Total pancreatectomy was performed. Between the cystic tumor and the solid tumor there was a distance of 4.8 cm of normal pancreatic parenchyma and duct, recognized both grossly and microscopically. The patient died 35 months after the operation. At autopsy, peritonitis carcinomatosa was found in the abdominal cavity. Microscopically, disseminated nodules were also well differentiated tubular adenocarcinoma. The apparent anatomic separation of these two tumors within the pancreas is extremely unusual.