Shinichi Yachida

A simple and safe pancreas transection using a stapling device for a distal pancreatectomy

Pancreatic fistula is the most common major complication to occur after distal pancreatectomy, ranging in frequency from 5% to 40%. The appropriate technique for treating the pancreatic stump still remains controversial. Thirty-six patients underwent distal pancreatectomy in Kagawa University Hospital between January 2000 and February 2007. Their hospital records were reviewed to evaluate the usefulness of a stapling closure using several types of staplers in comparison to a suture closure. They were subdivided according to the method used to close the pancreas stump: the suture group comprised 11 patients, the staple group comprised 24 patients, including 7 patients for whom was used the new endopath stapler Echelon 60 (Ethicon Endo-surgery; Johnson & Johnson, Cincinnati, OH, USA). Overall pancreatic fistula rate was 17% (6/36) in this series. In the staple group, 3 of the 24 patients (12%) developed a pancreatic fistula, whereas in the suture group, 3 of 11 patients (27%) developed a pancreatic fistula. Of the 7 patients for whom the Echelon 60 was used, none developed a pancreatic fistula. The length of postoperative hospital stay was also significantly shorter for the patients with the Echelon 60 than in the patients either with sutures or another stapling device. These findings support the advantages of using a stapler closure in distal pancreatectomy. This method, using a new stapler device, is considered to be a simple and safe alternative to the standard suture closure technique.

Neutrophil Elastase Inhibitor (Sivelestat) Preserves Antitumor Immunity and Reduces the Inflammatory Mediators Associated with Major Surgery

PurposeTo examine the effects of the administration of perioperative sivelestat, a selective neutrophil elastase inhibitor, on tumor immunity and inflammatory mediators in patients who undergo major surgery.MethodsThirteen patients admitted to the hospital for elective surgery were equally randomized into one of two groups: the Sivelestat group (n = 6) and the control group (n = 7). Thereafter, the immunosuppressive acidic protein (IAP), serum interleukin-6 (IL-6), and type 1/type 2 T-helper cell balance were all assessed at several time points before and after surgical intervention.ResultsThe serum IL-6 values at 1 and 12u2009h after surgery and on postoperative days 1 and 3 were all significantly lower in the sivelestat group than in the control group. The IAP values at postoperative days 7 and 28 in the sivelestat group were also significantly lower than those in the control group. There was a significant correlation between the IL-6 level at 1u2009h after surgery and the IAP level at postoperative days 7 and 28.ConclusionsIn this preliminary study, the perioperative administration of sivelestat was thus suggested to reduce surgical stress by decreasing the cytokine release and preserving the antitumor immunity.

Morphological and functional alterations to sinusoidal endothelial cells in the early phase of endotoxin-induced liver failure after partial hepatectomy in rats.

Abstractu2002Liver failure following major hepatectomy is characterized pathologically by massive hepatic necrosis, which is thought to begin with injury of sinusoidal endothelial cells (SECs). To examine the early events of SECs leading to hepatic damage, we performed time-course analyses of the morphological and functional perturbation of SECs after endotoxin administration to hepatectomized rats. At 1.5xa0h after endotoxin injection, when hepatocellular damage was not yet evident, SECs showed augmented expression of intercellular adhesion molecule-1, with frequent adherence of infiltrating leucocytes and ultrastructural features of defenestration and hypertrophied cytoplasm enriched with cell organelles. The serum level of hyaluronate, as an indicator of the functional state of SECs, was significantly elevated. At 3xa0h, SECs underwent necrosis and disruption, accompanied by fibrin deposits with concomitant hepatocellular necrosis. The morphological and functional alterations of SECs precede necrotic changes in hepatocytes and SECs in endotoxin-induced liver failure after partial hepatectomy.

Pancreatic thickness as a predictive factor for postoperative pancreatic fistula after distal pancreatectomy using an endopath stapler

PurposeNo consistent risk factor has yet been established for the development of pancreatic fistula (PF) after distal pancreatectomy (DP) with a stapler.MethodsA total of 31 consecutive patients underwent DP with an endopath stapler between June 2006 and December 2010 using a slow parenchymal flattening technique. The risk factors for PF after DP with an endopath stapler were identified based on univariate and multivariate analyses.ResultsClinical PF developed in 7 of 31 (22xa0%) patients who underwent DP with a stapler. The pancreata were significantly thicker at the transection line in patients with PF (19.4xa0±xa01.47xa0mm) in comparison to patients without PF (12.6xa0±xa00.79xa0mm; pxa0=xa00.0003). A 16-mm cut-off for pancreatic thickness was established based on the receiver operating characteristic (ROC) curve; the area under the ROC curve was 0.875 (pxa0=xa00.0215). Pancreatic thickness (pxa0=xa00.0006) and blood transfusion (pxa0=xa00.028) were associated with postoperative PF in a univariate analysis. Pancreatic thickness was the only significant independent factor (odds ratio 9.99; pxa0=xa00.036) according to a multivariate analysis with a specificity of 72xa0%, and a sensitivity of 85xa0%.ConclusionPancreatic thickness is a significant independent risk factor for PF development after DP with an endopath stapler. The stapler technique is thus considered to be an appropriate modality in patients with a pancreatic thicknesses of <16xa0mm.

Factors predicting survival and pathological subtype in patients with ampullary adenocarcinoma

Carcinoma of the ampulla of Vater is uncommon. This study aimed to clarify predictors of survival for ampullary adenocarcinoma and to identify characteristics of its two major pathological subtypes.

Pilot Feasibility Study of Neoadjuvant Chemoradiotherapy with S-1 in Patients with Locally Advanced Gastric Cancer Featuring Adjacent Tissue Invasion or JGCA Bulky N2 Lymph Node Metastases

BackgroundTo improve the prognosis of locally advanced gastric cancer, clinical trials of neoadjuvant chemotherapy (NAC) are being performed. Although neoadjuvant chemoradiotherapy (NACRT) generally achieves superior local tumor control to NAC, its efficacy for locally advanced gastric cancers remains unclear. Therefore, a prospective trial was conducted to explore the feasibility and safety of NACRT with oral S-1 in a series of cases.MethodsPatients who had Japanese Gastric Cancer Association (JGCA) cStage IIIB gastric cancer were enrolled onto this study and received oral S-1 (65xa0mg/m2/day) administration and 50-Gy radiotherapy followed by radical surgery. The primary end points were completion of therapy and safety.ResultsBetween October 2005 and September 2008, 12 eligible patients were enrolled. Two could not complete the chemotherapy because of grade 3 toxicity. R0 resections were performed in 11 patients (91.7xa0%) (95xa0% confidence interval 61.5–99.8). Although operative morbidity was observed in two cases, there were no postoperative deaths. A pathologic response was observed in 10 patients (83.3 %). In five (62.5 %) of eight gastric cancers with invasion to adjacent structures, microscopic tumor deposits were not found in the affected organs. The 3-year survival rate was 58.3 % during a median follow-up period of 36xa0months.ConclusionsAlthough this study is preliminary, the present regimen seems to be feasible and safe as a treatment for locally advanced gastric cancers featuring adjacent tissue invasion or JGCA bulky N2 disease. This treatment approach should now be tested using the new tumor, node, metastasis staging system in a large clinical trial.

Immunohistochemically Detected Expression of p27Kip1 and Skp2 Predicts Survival in Patients with Intrahepatic Cholangiocarcinomas

In intrahepatic cholangiocarcinomas (ICCs), the prognostic significance of p27Kip1, a cyclin-dependent kinase inhibitor, remains controversial, and there have been no studies of degradation pathway associated proteins, S-phase kinase-interacting protein (Skp2), and Jun activation domain-binding protein-1 (Jab1). In the present study of 74 patients with ICC–mass forming type (ICC-MF) undergoing radical surgery, we determined immunohistochemical expression of p27Kip1, Skp2, and Jab1 and examined relationships with clinicopathologic findings and patient survival. On the basis of the average of labeling indices, we set cutoff values to define high and low expressors and divided the cases into two groups. A statistically significant correlation was found between low p27Kip1 expression and lymph node metastasis (Pxa0=xa0.009). Patient survival in the low p27Kip1 expression group (nxa0=xa025) was also significantly worse than that in the high p27Kip1 expression group (nxa0=xa049, Pxa0=xa0.0007). A significant inverse correlation was found between p27Kip1 and Skp2 expression (Pxa0=xa0.016). High Skp2 expression (nxa0=xa036) was significantly associated with poor prognosis (Pxa0=xa0.0046). High Jab1 expression was observed in 32 cases, but there was no statistically significant relationship with clinicopathologic findings or patient survival. The multivariate analysis revealed that low p27Kip1 and high Skp2 expression are independent and significant factors of poor prognosis. The results suggest that low p27Kip1 and high Skp2 expression are associated with aggressive tumor behavior, and these cell-cycle regulators are useful markers to predict outcome of patients with ICC-MF.

Prediction of posthepatectomy hepatic functional reserve by serum hyaluronate

Serum hyaluronate can be used as an index of hepatic sinusoidal endothelial cell function and hepatic fibrosis. This study was designed to clarify the clinical significance of the serum hyaluronate level as a parameter of functional reserve.

Extraperitoneal colostomy in laparoscopic abdominoperineal resection using a laparoscopic retractor

Although extraperitoneal colostomy is often performed to prevent postoperative parastomal hernia formation following an open abdominoperineal resection of lower rectal cancer, it has not been widely employed laparoscopically because of the difficulty associated with the extraperitoneal route. This paper describes a laparoscopic extraperitoneal sigmoid colostomy using the Endo Retract™ Maxi instrument. This surgical technique is easy, and helps to prevent the development of parastomal hernias.

Endoscopically demonstrable esophageal changes after Helicobacter pylori eradication in patients with gastric disease

Background and Aims: An increased prevalence of reflux esophagitis has been reported following Helicobacter pylori (H. pylori) eradication in patients with duodenal ulcers in Western countries. However, it has remained unknown whether this might also appertain to individuals with other diseases. We therefore carried out this study to determine the effect of eradicating H. pylori infection in a series of Japanese patients.