Shunsuke Onoe

Prognostic delineation of papillary cholangiocarcinoma based on the invasive proportion: a single-institution study with 184 patients.

BACKGROUND Intraductal papillary neoplasm of the bile duct (IPNB) is a presumed precursor lesion in biliary carcinogenesis, clinicopathologically overlapping with papillary cholangiocarcinomas (PCC); however, because IPNB has no standardized definition, this relationship remains equivocal. Herein, we aimed to develop a new prognostic model for PCC by focusing on the invasive proportion. METHODS Among 644 patients with resected cholangiocarcinoma (1998-2011), 184 (28%) had intraductal, exophytic, papillary lesions. These were divided into 4 subsets based on the invasive component: Noninvasive (PCC-1; n = 14), ≤10% (PCC-2; n = 32), 11-50% (PCC-3; n = 60), and >50% (PCC-4; n = 78). The remaining 460 were identified as non-PCCs (NPCC). RESULTS Invasion beyond the duct wall and regional lymph node metastases were more frequent in NPCC than PCC (P < .001 for both). Five-year survival was better for PCC (55%) than NPCC (35%; P < .001), indicating the papillary component to be a significant, independent prognosticator. PCC-4 and NPCC had similar clinicopathologic features and overlapping survival curves: 33% and 35% at 5 years (P = .835), both less than those of PCC-1, PCC-2, and PCC-3 (respectively, 92%, 74%, and 64% at 5 years; P < .005 in all combinations). Multivariate analysis in PCC showed >50% invasive component, nodal metastasis, and a positive operative margin as independent predictors. CONCLUSION PCC survival decreased with progression of the invasive component. PCC with >50% invasive component was clinicopathologically similar to NPCC. Although IPNB might be nosologically applied only for PCC cases with ≤50% invasive component, the present prognostic delineation suggests that all PCC subgroups belonged to a singular disease group.

Determination of therapeutic strategy for adhesive small bowel obstruction using water-soluble contrast agents: An audit of 776 cases in a single center

Background. Several studies have investigated the diagnostic and therapeutic role of water‐soluble contrast agents in adhesive small bowel obstruction, but there is no clear diagnostic classification for the determination of therapeutic strategy. The aim of this study was to clarify the clinical value of classification using water‐soluble contrast agents in patients with adhesive small bowel obstruction. Methods. Between January 2009 and December 2015, 776 consecutive patients with adhesive small bowel obstruction were managed initially with water‐soluble contrast agents and were included in the study. Abdominal x‐rays were taken 5 hours after administration of 100 mL water‐soluble contrast agents and classified into 4 types. The medical records of the patients with adhesive small bowel obstruction were analyzed retrospectively and divided into 2 groups of patients with complete obstruction (ie, the absence of contrast agent in the colon) with (type I) or without (type II) a detectable point of obstruction and a group with an incomplete obstruction (ie, the presence of contrast agent in the colon) with (type IIIA) or without (type IIIB) dilated small intestine. Results. Types I, II, IIIA, and IIIB were identified in 27, 90, 358, and 301 patients, respectively. The overall operative rate was 16.6%. In the patients treated conservatively (types IIIA and IIIB), 647 patients (98.2%) were treated successfully without operative intervention. The operative rate was 3.4% (n = 12/358) in type IIIA vs 0% (n = 0/301) in the type IIIB group (P = .001). Compared with type IIIA, type IIIB was associated with earlier initiation of oral intake (2.1 vs 2.6 days, P < .001) and a lesser hospital stays (9 vs 11 days, P < .001). Conclusion. This new classification using water‐soluble contrast agents is a simple and useful diagnostic method for the determination of therapeutic strategy for adhesive small bowel obstruction.

Surgery for perihilar cholangiocarcinoma from a viewpoint of age: Is it beneficial to octogenarians in an aging society?

Background Whether operative treatment provides benefits for elderly patients with perihilar cholangiocarcinoma is unknown. The aim of this study was to review resection of perihilar cholangiocarcinoma according to age and to clarify its value for octogenarians. Methods Between April 1977 and December 2015, we reviewed consecutive patients who underwent resection for perihilar cholangiocarcinoma with a special focus on patient age. Results During the study interval, 831 patients underwent resection for perihilar cholangiocarcinoma. The median age of the resected patients increased by 11 years over approximately 40 years. Before 2001, no octogenarians underwent operative intervention; however, the proportion of operations for octogenarians increased to 9% after 2010. Further analyses were performed on 643 resected patients between 2001 and 2015. The resectability rate was not different between the octogenarians and the other age groups (71% vs 72.4%). The Charlson Comorbidity Index and preoperative laboratory data were similar between the 2 groups. A less advanced tumor was a predominant feature in the octogenarians compared to the other age groups. Consequently, the procedure used in the octogenarians were less extensive, but the proportion of R0 resection was greater in the octogenarians than in the other age groups (95.% vs 78.3%, P = .008). The ratio of patients who died of other diseases was also greater among octogenarians (29% vs 6.0%, P < .001). Overall survival was similar between the 2 groups (41% vs 38.9% at 5 years). Conclusion Resection of perihilar cholangiocarcinoma can be performed with low mortality irrespective of age with careful patient selection and offers long‐term survival even in octogenarians.

Comparison of outcomes of laparoscopy-assisted and open proximal gastrectomy with jejunal interposition for early gastric cancer in the upper third of the stomach: A retrospective observational study: Proximal gastrectomy

Laparoscopy‐assisted proximal gastrectomy with jejunal interposition (LAPG‐JI) is not yet widely used because the three anastomotic procedures involved in this operation are technically complicated. This study aimed to describe our surgical procedure for LAPG‐JI and assess its feasibility and safety.

Extracorporeal Hand-Sewn Anastomosis Through a Minilaparotomy in Laparoscopic Distal Gastrectomy

BACKGROUND Various methods of reconstruction after laparoscopic distal gastrectomy (LDG) have been developed and reported. In open gastrectomy, gastroduodenostomy or gastroenterostomy is often performed with the hand-sewn technique. Therefore, hand-sewn anastomosis was performed through a small incision in LDG. The aim of this study was to evaluate the feasibility and safety of LDG with hand-sewn anastomosis. METHODS Between June 2009 and December 2015, we assessed 263 consecutive patients who underwent LDG in our institution. In all patients, the reconstruction procedures were performed extracorporeally with the hand-sewn technique. The clinical characteristics, surgical outcomes, and operation cost related to anastomosis were evaluated and compared with the other methods. RESULTS The average operation time was 157.5 minutes, and average blood loss was 38.8 mL. The types of reconstruction were Billroth I, 95 cases (36.1%); Billroth II, 165 cases (62.7%); and Roux-en-Y, 3 cases (1.1%). The overall incidence of postoperative complications (Clavien-Dindo classification≧Grade II) was 8.0%. Anastomotic leakage was observed in 1 patient (0.4%) and anastomotic bleeding and anastomotic stenosis in 2 patients each (0.8%). There was no postoperative mortality. The cost of the absorbable threads used in anastomosis is less than the cost of a linear or circular stapler, which is often used in intracorporeal anastomosis. CONCLUSION This procedure is similar to conventional open surgery, and it is feasible, safe, and cost-effective. In addition, in an institution that plans to introduce LDG, the use of our method during the introductory phase of LDG has many advantages.