Takuya Okumura

Clinicopathological prognostic factors and impact of surgical treatment of mass-forming intrahepatic cholangiocarcinoma.

The clinicopathological characteristics relevant to prognosis after surgical treatment of intrahepatic cholangiocarcinoma (ICC) remain unclear. In this study, the clinicopathological features of 19 patients with mass-forming ICC, the most common form of the disease, were reviewed to analyze prognostic determinants. Two or more segmentectomies of the liver with systematic lymphadenectomy were performed in 18 patients. Resection of the extrahepatic bile duct was performed in 14 patients, and reconstruction of the portal vein was accomplished in 5 patients. Stage IVA or IVB tumors were seen in 13 patients, and lymph node (LN) metastasis was present in 14 patients. The estimated 5-year survival rate after surgery for mass-forming ICC was 28%, with median survival time of 18 months. In univariate analysis, five variables were determined to be significantly correlated with poor survival of patients with mass-forming ICC after surgery. These variables include mass-forming ICC with periductal infiltration, perineural invasion, portal vein invasion, presence of intrahepatic metastasis, and two or more LN metastases. Survival rates of 5 patients without LN metastasis and 6 patients with a single LN metastasis were 80% and 33% at 5 years, respectively, while 8 patients with two or more LN metastasis failed to survive beyond 2 years. Multivariate analysis revealed the presence of intrahepatic metastasis to be an independent prognostic factor of poor survival. Hepatectomy with resection of the extrahepatic bile duct and systematic lymphadenectomy yields a good chance for prolonged survival for patients with mass-forming ICC when the lesion is singular and LN metastasis is limited to a regional LN. Because the presence of intrahepatic metastasis was closely related to a poor prognosis in patients with mass-forming ICC, efficacious chemotherapy would be needed to control development of the lesion.RésuméLes caractéristiques clinicopathologiques influençant le pronostic après traitement des cholangiocarcinomes intra-hépatiq.ues (CIH) ne sont pas claires. Dans cette étude, les caractéristiques clinicopathologiques chez 19 patients porteurs de CIH à forme tumorale, la forme la plus fréquente, ont été analysés à des fins pronostiques. On a réalisé une segmentectomie de deux segments ou plus avec lymphadénectomie systématique chez 18 patients, une résection des voies biliaires extra-hépatiques chez 14 et une reconstruction de la veine porte chez 5 patients. Treize patients avaient une tumeur stade IVA ou IVB; 14 avaient des métastases ganglionnaires. La survie à 5 ans après chirurgie pour CIH à forme tumorale a été de 28%; la médiane de survie a été de 18 mois. En analyse univariée, on a trouvé cinq variables significativement associées à une survie médiocre chez les patients opérés de CIH à forme tumorale. Ces variables sont un CIH avec infiltration péricanulaire, un envahissement perineural, un envahissement portai, la présence de métastases hépatiques, et des métastases de deux ganglions ou plus. La survie de cinq patients sans métastase ganglionnaire et de six patients avec une seule métastase ganglionnaire ont été, respectivement, de 80% et de 33% à 5 ans, alors qu’aucun des huit patients avec deux métastases ganglionnaires ou plus n’a survécu au-delà de deux ans. En analyse multivariée, la présence de métastases intrahépatiques était un facteur indépendant de mauvais pronostic. Une hépatectomie avec résection des voies biliaires extra-hépatiques associée à un curage lymphatique systématique améliore les chances de survie prolongée en cas de CIH à forme tumorale lorsque la lésion est unique et les métastases ganglionnaires sont limitées à un seul ganglion lymphatique régional. Puisque la présence de métastases intrahépatiques est étroitement en rapport avec un mauvais pronostic chez les patients porteurs de CIH à forme tumorale, une chimiothérapie efficace est nécessaire pour contrôler l’évolution.ResumenTras el tratamiento quirúrgico, las características clínicopatológicas pronósticas más importantes para los pacientes con colangiocarcinomas intrahepáticos (ICC) son poco conocidas. En este estudio se revisan las características clínicopatológicas más frecuentes en 19 pacientes con grandes tumores ICC, con objeto de determinar los factores pronósticos más importantes. 18 casos fueron tratados mediante dos o más segmentectomías hepáticas y linfadenectomía sistemática. En 14 pacientes se procedió a la resección y subsiguiente reconstrucción de la vía biliar extrahepática y en 5 de la vena porta. 13 pacientes pertenecían al estadio IV A o IV B y adenopatias metastásicas (LN) se registraron en 14 enfermos. Tras el acto quirúrgico el porcentaje medio estimado de supervivencia a los 5 años fue del 28%, con un tiempo de supervivencia de 18 meses. En pacientes con ICC que cursan con una tumoración macroscópicamente visible y palpable, el análisis univariante detectó 5 variables significativas por lo que a la escasa supervivencia se refiere: tumoración ICC con infiltración periductal, invasión perineural o de la vena porta, existencia de metástasis intrahepáticas y 2 o más adenopatías (LN) metastásicas. La supervivencia a los 5 años de 5 pacientes sin metástasis ganglionares (LN) y con una sola adenopatía metastásica fue del 80% y 33%, mientras que 8 pacientes con dos o más adenopatias metastásicas (LN) no sobrevivieron más de 2 años. El análisis multivariante demostró que las metástasis intrahepáticas constituyen un factor pronóstico independiente, de escasa supervivencia. La hepatectomía con resección de la vía biliar extrahepática asociada a una sistemática linfadenectomia puede, con suerte, prolongar la supervivencia de pacientes con tumores ICC palpables, cuando la tumoración es única y las adenopatias metastásicas son exclusivamente regionales. Dado que la presencia de metástasis intrahepáticas es signo de mal pronóstico, se precisa una eficaz quimioterapia para controlar el desarrollo de este tumor.

A 5-year survivor after resection of peritoneal metastases from pedunculated-type hepatocellular carcinoma.

We report herein a 5-year survivor after the resection of peritoneal metastases from pedunculated hepatocellular carcinoma (HCC). A 42-year-old man underwent lateral segmentectomy of the liver, with a diagnosis of pedunculated HCC, on October 10, 1994. The lesion was associated with intratumoral hemorrhage and was covered by the greater omentum, but there were no peritoneal metastases. The patient was readmitted to our hospital 4 months later with right upper quadrant pain. His serum alpha-fetoprotein level was 3ng/dl. Hepatitis B virus surface antigen (HBsAg) and hepatitis C virus antibody (HCV-Ab) were both negative. Abdominal computed tomography (CT) revealed two nodular lesions in the right upper abdominal cavity. He was diagnosed with peritoneal metastases from HCC. Because there were no other distant metastases, laparotomy was performed to resect these tumors. We found two other tumors, located in the mesentery of the appendix and ileum. All four tumors were resected by partial transverse colectomy and appendectomy. The histopathology of the tumors showed poorly differentiated HCC (Edmondson-Steiners grade III). The patient has been doing well without recurrent disease for more than 5 years after the second operation. The prognosis of patients with pedunculated HCC is poor. Furthermore, resection for peritoneal metastases from HCC is rare because of the presence of multiple seeding in the abdominal cavity and distant organ metastases. To our knowledge, our patient is the longest survivor after resection of peritoneal metastases from pedunculated HCC.

Portal Vein Thrombosis Caused by Microwave Coagulation Therapy for Hepatocellular Carcinoma: Report of a Case

Abstract Microwave coagulation therapy (MCT) is one of the treatment modalities for patients with hepatocellular carcinoma (HCC). A 67-year-old man with liver cirrhosis underwent MCT during a laparotomy for a deeply located HCC (2.5 cm in diameter) at the border of the anterior and posterior segments of the right hepatic lobe. Two weeks after MCT, he complained of abdominal fullness. Portal vein thrombosis (PVT) was diagnosed because he had massive ascites and an echogenic mass in the portal vein on abdominal ultrasonography. PVT was successfully treated by fibrinolytic therapy with a selective infusion of urokinase via the superior mesenteric artery (SMA). There have been few reports on PVT as a complication of MCT. Attention should be paid to the possible occurrence of PVT as a critical complication after MCT for liver tumors adjacent to the portal vein. Fibrinolytic therapy via the SMA is thus considered to be an effective approach for PVT after MCT.

Periodic measurement of serum carcinoembryonic antigen and carbohydrate antigen 15-3 levels as postoperative surveillance after breast cancer surgery.

PurposeBreast cancer surveillance guidelines do not recommend routine tumor marker testing after surgery, despite which it is still widely performed in Japan. We investigated the clinical utility of postoperative tumor marker testing in a series of Japanese patients, in view of the fact that all the studies to date have been non-Japanese.MethodsWe retrospectively analyzed the lead time by periodic measurements of serum carcinoembryonic antigen (CEA) and carbohydrate antigen 15-3 (CA15-3) in 233 patients who underwent breast cancer surgery. Both tumor marker levels were measured every 3 months for the first 5 years, every 6 months for the next 5 years, then annually. Physical examination and chest X-ray were routinely done at the same time, and bone or computed tomographic scans were done if the tumor marker levels were elevated or clinical symptoms appeared.ResultsIn patients with recurrent disease, the mean lead times were −333.9 days for CEA and −210.6 days for CA15-3, respectively. Elevated tumor marker levels were found much later than recurrence.ConclusionOur results support the American Society of Clinical Oncology guidelines. Thus, the serial testing of tumor marker levels after breast cancer surgery may not be as beneficial as thought in Japan.

Long-term survival after report resection of pulmonary metastases from hepatocellular carcinoma: report of two cases.

Hepatocellular carcinoma (HCC) is often treated most effectively by resection. Although improved surgical procedures and perioperative care have made hepatic resection safe, the prognosis of patients with HCC is still poor because of the high incidence of postoperative recurrence. The most common site of extrahepatic recurrence is the lung. However, because of its multiplicity and concurrent recurrence in the liver remnant, resection of pulmonary metastases form HCC is rarely beneficial. We report two cases of long-term survival after repeated pulmonary resection of metastasis from HCC. At the time of this report the two patients were free of disease, 110 months and 107 months, respectively, after their initial hepatectomy. These case reports show that pulmonary metastases from HCC can be successfully resected in selected patients.

Ileo-ileal intussusception caused by lymphangioma of the small bowel treated by single-incision laparoscopic-assisted ileal resection

Intraabdominal lymphangiomas are uncommon; additionally, those affecting the gastrointestinal tract are rare and account for less than 1% of cases. Intussusception caused by a cystic lymphangioma of the small bowel is extremely rare. The patient was a 20-year-old woman who visited our emergency room with a complaint of abdominal pain. A computed tomography image revealed ileo-ileal intussusception with a leading hypovascular mass measuring 1 cm in a diameter. Single-incision laparoscopic-assisted ileal resection was performed. The surgical specimen consisted of a soft polycystic mass. Macroscopically, a pedunculated polyp with a convolutional pattern was found. Microscopically, the inner surfaces of the cysts were covered with a single layer of endothelial cells. On immunohistochemical examination, the endothelial cells were partially positive for D2-40 and CD34. Smooth muscle cells were also found around the cysts. The lesion was diagnosed as a cystic lymphangioma. Dozens of cases of small bowel lymphangiomas have previously been reported. Of these, cases with intussusception were very rare. This is the first case of small bowel intussusception due to lymphangioma treated by single-incision laparoscopic-assisted surgery.

Elective laparoscopic repair after reduction might be useful strategy for incarcerated obturator hernia: a case report

Abstract Obturator hernia is a rare clinical condition that causes intestinal obstruction. Recent reports have suggested that laparoscopic repair may be useful for incarcerated obturator hernia in select patients. The patient was a 64-year-old female who presented to our emergency department with a chief complaint of abdominal pain. Computed tomography (CT) imaging revealed an incarcerated obturator hernia on her right side, without apparent findings of irreversible ischaemic change or perforation. She had a previous history of cardiovascular surgery and was taking an anticoagulant medication. We performed a reduction of the incarcerated intestine. After heparin displacement, laparoscopic repair was electively performed. During laparoscopy, an occult obturator hernia was found on the left side. We repaired the bilateral obturator hernia using a mesh prosthesis. Elective laparoscopic repair after reduction might be a useful procedure for incarcerated obturator hernias in those patients without findings of irreversible ischaemic change or perforation.

Torsion of Atypical Meckel’s Diverticulum Treated by Laparoscopic-Assisted Surgery

Introduction Meckels diverticulum (MD) is the most common congenital anomaly of the intestine, with an incidence of 2~4%. Of those, only 2% of patients with MD are symptomatic. Torsion of MD is extremely rare, and only a dozen cases have been previously reported. Case Report The patient was a 49-year-old male who presented to our emergency room with a chief complaint of lower abdominal pain. Computed tomography imaging revealed an irregular polycystic mass connected to the small intestine that measured 7.5 cm in a diameter. A laparoscopic-assisted partial resection of the jejunum was performed. The lesion was found to have caused torsion and was located 130 cm from the ileocecal valve. The specimen was polycystic in appearance and showed communicating links with the submucosal layer of jejunum but not with the lumen. The pathological diagnosis was a torsion of an atypical presentation of MD. Conclusion This case was different from typical cases of MD in that it was located on significantly oral side and had the appearance of polycystic morphology.

Case of reduction en masse who presented with no symptoms: Case of reduction en masse

The early and accurate diagnosis of reduction en masse followed by proper treatment is important but has been difficult. Here, we report the case of a 58‐year‐old Japanese man who presented with abdominal pain and vomiting at a nearby clinic. He was referred to our hospital on suspicion of small bowel obstruction. Despite the total disappearance of his symptoms, the abdominal X‐ray examination showed distended loops of small bowel. The preoperative diagnosis of small bowel strangulation due to an internal hernia was made by CT, and we therefore performed emergency exploratory laparoscopy. We intraoperatively diagnosed the patient with the reduction en masse of a right inguinal hernia, and we conducted a transabdominal preperitoneal hernioplasty. This patients case demonstrates that even when a patient is asymptomatic after the reduction of an inguinal hernia, the possibility of a reduction en masse remains.

Is postponed laparoscopic cholecystectomy justified for acute cholecystitis appearing early after onset?: Postponed laparoscopic cholecystectomy

Early laparoscopic cholecystectomy (ELC) is considered the standard treatment for acute cholecystitis for patients who can tolerate surgery. The ideal time for performing ELC is reported to be 72 h from onset. However, many patients undergo surgery on or after the fourth day from onset, even if they presented early after onset. A few reports have investigated the feasibility and disadvantages of this so‐called “postponed laparoscopic cholecystectomy” (PLC).