Takeshi Sudo

Pancreatoduodenectomy for Distal Cholangiocarcinoma: Prognostic Impact of Lymph Node Metastasis

BackgroundThe aim of this study was to identify useful prognostic factors in patients undergoing pancreatoduodenectomy for distal cholangiocarcinoma.MethodsThe records of 36 patients with distal cholangiocarcinoma undergoing pancreatoduodenectomy were retrospectively reviewed. Potential clinicopathological prognostic factors that may affect survival were examined by univariate and multivariate analysis.ResultsThere was no mortality. Overall survival rates were 75%, 54%, and 50% for 1, 3 and 5 years, respectively (median survival time, 26 months). Univariate analysis found that age (≧ 65 years), pancreatic invasion, duodenal invasion, lymph node metastasis, perineural invasion and a positive surgical margin were significant predictors of poor prognosis (P < 0.05). Furthermore, lymph node metastasis was found to be a significant independent predictor of poor prognosis by multivariate analysis (P = 0.043). Moreover, there were significant differences in the 5-year survival between patients with 2 or less involved lymph nodes and those with 3 or more positive nodes (P < 0.001). There were no 2-year survivors of the group of patients with 3 or more positive nodes.ConclusionsThese results suggest that the presence and number of lymph nodes exhibiting metastatic disease might be useful in predicting the postsurgical outcome in patients undergoing pancreatoduodenectomy for distal cholangiocarcinoma.

An Antecolic Roux-en Y type Reconstruction Decreased Delayed Gastric Emptying after Pylorus-Preserving Pancreatoduodenectomy

The aim of this study was to identify a preferable procedure reducing the incidence of delayed gastric emptying (DGE) after pylorus-preserving pancreatoduodenectomy (PPPD). Data on 132 consecutive patients with pancreatobiliary disease, who underwent PPPD, were collected retrospectively. A retrocolic Billroth I type reconstruction (B-I group) and an antecolic Roux-en Y type reconstruction (R-Y group) were performed for 54 and 78 patients after PPPD, respectively. Clinical measures of DGE were compared between the two groups. The incidence of DGE was 81% in B-I group and 10% in R-Y group (Pu2009<u20090.001). The type of reconstruction (Pu2009<u20090.001), operative time (Pu2009=u20090.016), and postoperative complications (Pu2009=u20090.001) were significantly associated with DGE by univariate analysis. Only the type of reconstruction (Pu2009<u20090.001) was identified as an independent factor, which was associated with DGE by multivariate analysis. An antecolic Roux-en Y type duodenojejunostomy could be a useful reconstruction method after PPPD to prevent the occurrence of DGE.

Predictive Factors of Malignant or Invasive Intraductal Papillary-Mucinous Neoplasms of the Pancreas

The aim of this study was to identify useful preoperative diagnostic findings indicative of malignant or invasive intraductal papillary-mucinous neoplasms (IPMN) of the pancreas to determine an optimal operative procedure for IPMN. Sixty-two IPMNs, which consisted of 29 adenomas, 10 borderline tumors, 11 adenocarcinomas in situ, and invasive adenocarcinomas were reviewed from 1990 to 2003. Preoperative predictive factors of malignant or invasive IPMN were analyzed among 10 factors by univariate and multivariate analysis. Diameter of the main pancreatic duct (≧6xa0mm) and cytological examination of the pancreatic juice (the presence of malignant cells) were identified as independent predictive factors of malignant IPMN, and only cytological examination of the pancreatic juice (the presence of malignant cells) was identified as an independent predictor of invasive IPMN by multivariate analysis (Pu2009<u20090.05). There was no recurrent disease in patients with adenoma and adenocarcinoma in situ, whereas recurrences occurred in 6 of 12 patients with invasive IPMN. Patient survival in noninvasive IPMN was significantly (Pu2009=u20090.018) better than that in invasive IPMN (The overall 5-year survival rates were 87.2% and 49.2%, respectively). These results might be useful for selecting an optimal surgical procedure for IPMN.

Adjuvant gemcitabine plus S-1 chemotherapy after surgical resection for pancreatic adenocarcinoma

BACKGROUNDnThe aim of this study was to determine the effectiveness of adjuvant gemcitabine plus S-1 chemotherapy for patients with pancreatic carcinoma.nnnMETHODSnPatients admitted for curative surgery for pancreatic adenocarcinoma received adjuvant chemotherapy with 10 cycles of gemcitabine plus S-1 every 2 weeks. Each chemotherapy cycle consisted of intravenous gemcitabine, 700 mg/m(2), on day 1 and orally administered S-1, 50 mg/m(2), for 7 consecutive days, after which there was a 1-week pause of chemotherapy.nnnRESULTSnTwenty-seven patients were entered into this study. According to the TNM system, 4 (15%), 2 (7%), 6 (22%), and 15 (56%) patients were diagnosed with stage IA, IB, IIA, and IIB disease, respectively. Overall and disease-free survival rates were 86% and 60% at 1 year, 66% and 45% at 2 years, and 33% and 45% at 3 years, respectively. Toxicity during chemotherapy was mild.nnnCONCLUSIONSnAdjuvant gemcitabine plus S-1 chemotherapy appears to be a promising treatment for patients after surgical resection of pancreatic adenocarcinoma.

Intraductal papillary-mucinous neoplasms and mucinous cystic neoplasms of the pancreas differentiated by ovarian-type stroma

BACKGROUNDnIntraductal papillary-mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN) of the pancreas have similar clinicopathologic findings. This study was intended to clarify clinicopathologic characteristics in IPMNs and MCNs differentiated by ovarian-type stroma.nnnMETHODSnMedical records for 77 patients with pancreatic cystic neoplasms with mucin secretion were reviewed. Patients were divided into IPMN (n = 70) or MCN (n = 7) according to the presence of ovarian-type stroma, and clinicopathologic parameters were compared between groups.nnnRESULTSnIPMNs consisted of 32 adenomas, 12 borderline neoplasms, 13 adenocarcinomas in situ, and 13 invasive adenocarcinomas; MCNs included 6 adenomas and 1 invasive adenocarcinoma. The mean age of IPMN patients (66 years) was significantly older than that of MCN patients (55 years). The male:female ratio in IPMN (53/17) was significantly greater (P < .001) than in MCN (0/7). The location of the pancreatic mass differed, with 76% 0f IPMNs occurring in the head, while 86% of MCNs occurred in the body or tail. Mass mean size was significantly smaller (28 mm vs 78 mm, P < .001), and mean diameter of the main pancreatic duct was larger (6.8 mm vs 3.1 mm, P < .001) in IPMN than in MCN. Patulous papilla was present in 44% (31/70) of IPMNs, but none was present in MCNs. Communication between the cyst and main pancreatic duct was more frequent in IPMNs (67/70) than in MCNs (1/7). Overall 5-year survival rates were 84% (IPMN) and 100% (MCN).nnnCONCLUSIONSnClinicopathologic differences between IPMN and MCN are much clearer when differentiated by presence of ovarian-type stroma. Favorable prognosis for both neoplasms is offered by complete resection.

Specific Antibiotic Prophylaxis Based on Bile Cultures Is Required to Prevent Postoperative Infectious Complications in Pancreatoduodenectomy Patients Who Have Undergone Preoperative Biliary Drainage

BackgroundPreoperative biliary drainage (PBD) is associated with bacterial contamination of bile, but the effects of PBD on morbidity after pancreatoduodenectomy remain controversial. The aim of this study was to characterize bile contamination to develop successful specific antibiotic prophylactic strategies for pancreatoduodenectomy.MethodsNinety-one consecutive patients who underwent pancreatoduodenectomy for periampullary tumor were prospectively evaluated. Prophylactic antibiotics were selected based on preoperative bile cultures. Bile cultures and postoperative complications were compared in 46 patients who underwent PBD (drainage group) versus 45 patients who did not (nondrainage group).ResultsThe incidence of positive bile cultures was higher in the drainage group (78%) than in the nondrainage group (36%) (Pxa0<xa00.001). In the drainage group, positive bile cultures were frequently polymicrobial (61%) and demonstrated resistance to several antibiotics, including cefazolin (83%), cefmetazole (72%), and cefpirome (64%). Overall morbidity (30% and 22%) and infectious morbidity (13% and 11%) did not differ significantly between the drainage and nondrainage groups, respectively.ConclusionsPBD had a notable influence on bile microbial contamination, including a higher rate of antibiotic resistance. Therefore, specific antibiotic prophylaxis based on bile culture is required for preventing infectious complications in pancreatoduodenectomy patients who undergo PBD.

Impact of Adjuvant Gemcitabine Plus S-1 Chemotherapy After Surgical Resection for Adenocarcinoma of the Body or Tail of the Pancreas

BackgroundFew patients with pancreatic body or tail carcinoma are candidates for surgical resection, and the efficacy of postoperative adjuvant chemotherapy for patients with pancreatic body or tail carcinoma has not been elucidated. The aim of this study was to determine the effect of adjuvant gemcitabine and S-1 therapy for patients with adenocarcinoma of the body or tail of the pancreas who had undergone surgical resection by distal pancreatectomy.Materials and MethodsMedical records of 34 patients with pancreatic body or tail carcinoma who underwent surgical resection were reviewed retrospectively. Eighteen patients received postoperative adjuvant gemcitabine and S-1 chemotherapy. Univariate and multivariate models were used to analyze the effect of various clinicopathological factors on long-term survival.ResultsThere were no deaths due to surgery. Overall, 1-, 2-, and 5-year survival rates were 69%, 40%, and 25%, respectively (median survival time, 14.4xa0months). Univariate analysis revealed that adjuvant gemcitabine plus S-1 chemotherapy, blood transfusion, splenic artery invasion, lymph node metastasis, surgical margin status, and International Union Against Cancer stage were associated significantly with long-term survival (Pu2009<u20090.05). Furthermore, use of a Cox proportional hazards regression model indicated that adjuvant gemcitabine plus S-1 chemotherapy and absence of lymph node metastasis were significant independent predictors of a favorable prognosis (Pu2009<u20090.05).ConclusionPostoperative adjuvant gemcitabine plus S-1 chemotherapy may improve survival after surgical resection for pancreatic body or tail carcinoma.

Telomere Shortening and Telomerase Expression during Multistage Carcinogenesis of Intraductal Papillary Mucinous Neoplasms of the Pancreas

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas has been increasingly identified as a precursor to infiltrating ductal adenocarcinoma. Telomerase activation in response to telomere crisis followed by telomere shortening is thought to be a crucial event in the development of most human cancers. The aim of this study was to determine when this event occurs in the context of histologically defined IPMN progression. We analyzed telomerase expression in 68 IPMN samples and assessed telomere length by quantitative fluorescence in situ hybridization in samples taken from 17 sequential IPMN patients that included 37 individual loci. Samples from pancreatic ductal adenocarcinomas (PDACs, nu2009=u200915) and chronic pancreatitis patients (nu2009=u200910) were also examined. Telomeres were significantly shortened in 36 (97.3%) of 37 IPMN loci, with average telomere length decreasing with IPMN progression. Notably, even adenoma IPMNs demonstrated a 50% reduction of telomere length in 7 of 14 foci examined. Marked telomere shortening was observed from the in situ IPMN carcinoma stage (Pu2009<u20090.001; vs borderline IPMNs) through the invasive stage, although telomerase had been activated, indicating that telomeres had shortened to a critical length by this histological grade. Up-regulated human telomerase reverse transcriptase expression was detectable and increased gradually with cancer development and was primarily observed at the borderline IPMN stage and then in more advanced histopathologies. Progressive telomere shortening predominantly occurs during early IPMNs carcinogenesis before telomerase activation and progression from borderline to carcinoma in situ IPMNs is the critical stage of IPMNs carcinogenesis at which telomere dysfunction occurs.

Usefulness of a 13C-labeled mixed triglyceride breath test for assessing pancreatic exocrine function after pancreatic surgery

BACKGROUNDnAlthough the fecal elastase-1 test is a satisfactory pancreatic exocrine function test, breath tests that use stable isotopes have been developed recently as alternatives. We evaluated the usefulness of a (13)C-labeled mixed triglyceride breath test for assessing pancreatic exocrine function after pancreatic surgery.nnnMETHODSnThe breath test and the fecal elastase-1 test were performed on 7 healthy volunteers, 10 patients with chronic pancreatitis, and 95 patients after pancreatic surgery. The breath test was analyzed with isotope ratio mass spectrometry and the cumulative recovery of (13)CO(2) at 7 hours (% dose (13)C cum 7h) was calculated. The fecal elastase-1 concentration was determined immunoenzymatically.nnnRESULTSnBoth the fecal elastase-1 concentration and the % dose (13)C cum 7h of chronic pancreatitis patients and pancreatic resection patients were less than those of healthy volunteers. In all subjects, % dose (13)C cum 7h correlated with the fecal elastase-1 concentration (n = 112, R(2) = 0.14, P < .01). Accuracy rates for clinical symptoms, including clinical steatorrhea, for the fecal test and the breath test were 62 and 88%, respectively.nnnCONCLUSIONnThe (13)C-labeled mixed triglyceride breath test might be more useful than the fecal elastase-1 test for evaluating pancreatic exocrine function after pancreatic resection.

A Soft Pancreatic Remnant is Associated with Increased Drain Fluid Pancreatic Amylase and Serum CRP Levels Following Pancreatoduodenectomy

The aim of this prospective study was to clarify differences in postoperative changes of serum or drainage fluid pancreatic amylase levels and serum C-reactive protein (CRP) levels between patients with a soft pancreatic texture and those with a hard pancreatic texture undergoing pancreatoduodenectomy (PD) with pancreaticogastrostomy. A total of 61 consecutive patients with resectable periampullary tumors undergoing PD were recruited. This population was divided into 27 patients with a hard pancreatic texture and 34 patients with a soft pancreatic texture. Drainage fluid total amylase or pancreatic amylase levels, serum total amylase or pancreatic amylase levels, and serum CRP levels were measured postoperatively. Clinicopathological data were also compared between two groups. Postoperative complications more frequently occurred in patients with a soft pancreatic texture compared with those with a hard pancreatic texture (Pu2009=u20090.029). Serum or drainage fluid pancreatic amylase levels and serum CRP levels of patients with a soft pancreatic texture were significantly higher than those of patients with a hard pancreatic texture after PD on postoperative days 1 and 2 (Pu2009<u20090.05). A soft pancreatic texture was identified as an only independent predictive factor of increased drainage fluid pancreatic amylase levels (Pu2009=u20090.006) and serum CRP levels (Pu2009=u20090.047). A soft pancreatic texture is closely associated with increased drainage fluid pancreatic amylase and serum CRP levels after PD. More careful post-PD management is needed for patients with a soft pancreatic texture.