Tatsushi Naganuma

Surgical Treatment of Hilar Bile Duct Carcinoma: Experience With 25 Consecutive Hepatectomies

To evaluate our recent surgical policy regarding hilar bile duct carcinoma, we evaluated 62 cases treated between 1976 and 1993, and 25 cases treated between 1994 and 2000. In the late period we used percutaneous transhepatic portal vein embolization (PTPE) before extended right hepatectomy; S4a + S5 + S1 hepatectomy for elderly patients and those with poor liver function; and routine total caudate lobectomy including the paracaval portion and resection of the inferior portion of the medial segment (S4a). Sixtyfive (74.7%) of the 87 patients underwent hepatectomy: 40 in the early period and 25 in the late period. Bile duct resection alone was performed in 22 patients, all in the early period. Resection was curative in 54.8% in the early period and 88.0% in the late period. The 3- and 5-year survival rates in the early period were 27.1% and 20.2%, respectively, as compared to 59.9% and 49.9% in the late period. Analysis of the 25 hepatectomies in the late period revealed improved survival times compared to patients treated by PTPE with extended right hepatectomy. No complications occurred after extended left hepatectomy or S4a + S5 + S1 hepatectomy, but four patients (16%) who underwent extended right hepatectomy plus PTPE died postoperatively. Our policy has resulted in improved outcome in patients with hilar bile duct carcinoma.

Staging and extended resection for pancreatic cancer.

Extended surgery is being widely performed to treat pancreatic cancer in Japan, but it has not been evaluated in the same way as in other countries. We, therefore, compared the Japanese Stage Classification (JPN-SC) with the Union Internationale Contre le Cancer Stage Classification (UICC-SC) in the surgical cases of pancreatic cancer treated in our department and then assessed the results of extended resection and associated problems. Problems existed in the resection rates and actuarial survival rates in stages II and III in the UICC-SC, and the JPN-SC was found to reflect more accurately the outcome. On the other hand, although improvements in curative resection and actuarial survival rate have been achieved as a result of extended resection in Japan, the outcome in JPN-SC surgical stage IVb and highly advanced cases in which these resections proved to be noncurative even though they were classified as surgical stage IVa was extremely poor. In the future, it will be necessary to decide on a single-stage classification that is accepted throughout the world and to conduct prospective studies matched to the degree of tumor progression.

Modified standard pancreaticoduodenectomy for the treatment of pancreatic head cancer

Since 1980 extended surgery has been used to treat pancreatic cancer in many institutions in Japan in the hope of achieving curative resection and a good outcome. The resection rate increased, but the final outcome was unsatisfactory, and the question of postoperative quality of life (QOL) following extended surgery has instead become the central issue. During the past 22 years (October 1976 to June 1998) 169 of the 188 patients with invasive pancreatic ductal carcinoma at Mie University Hospital were treated surgically. A standard operation was performed in the early period (October 1976 to April 1981, n = 34), an extended operation was performed in the middle period (May 1981 to March 1993, n = 100), and a modified standard operation was performed in the late period (April 1993 to June 1998, n = 35). ‘Standard operation’ means pancreaticoduodenectomy (PD) with D1 lymph node dissection (regional), and ‘extended operation’ means PD with D2–D3 lymph node dissection. Our ‘modified standard operation’ consists of PD with lymph node dissection limited to the anterior pancreaticoduodenal (APD), posterior pancreaticoduodenal (PPD), pyloric (PY), hepatoduodenal ligament (HDL), common hepatic artery (CH) and right half of the superior mesenteric (SM) nodes. Thus, the extent of lymph node dissection in the modified standard procedure lies between the level in the standard and extended procedure, but the PD is the same, with only slight modification in the reconstruction procedure. We consider the standard operation to be a less curative procedure and the extended operation to be a very stressful procedure and accordingly we have modified it (modified standard operation) in our recent cases out of consideration for patients’ QOL. We found that postoperative QOL and survival were much better in the late period than in the early and middle periods.

Primary non‐Hodgkin's lymphoma of the gallbladder diagnosed by laparoscopic cholecystectomy

Primary lymphoma of the gallbladder is an exceedingly rare disease. We experienced an asymptomatic case of primary non-Hodgkins lymphoma of the gallbladder in a 55-year-old woman in whom laparoscopic cholecystectomy made a definite diagnosis. Abdominal computed tomography revealed a 4-cm gallbladder tumor with markedly enlarged lymph nodes in the retropancreatic area. Despite the marked involvement of lymph nodes, serum levels of carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 were not elevated. The discrepancy between the imaging findings and the patients mild clinical presentation led us to suspect that the tumor was a lymphoma. We examined serum markers of lymphoma, revealing slight elevations of interleukin (IL)-2 receptor and thymidine kinase. Laparoscopic cholecystectomy for a total biopsy was performed successfully, and the results of intraoperative frozen-section examination led us to have a high suspicion of malignant lymphoma. The final diagnosis was large diffuse B-cell lymphoma of the gallbladder with a positive CD20 antibody reaction. The patient received postoperative chemotherapy with R-CHOP (rituximab, 500 mg; cyclophosphamide, 1000 mg; adriamycin, 68 mg; vincristine, 1.9 mg; and prednisone, 80 mg) starting on postoperative day 12. She achieved complete remission and is still in complete remission 3 years and 2 months after the cholecystectomy. In conclusion, gallbladder lymphoma should be added to the differential diagnosis of gallbladder tumors, especially when the imaging findings and clinical presentation are not consistent with typical signs of gallbladder carcinoma, and laparoscopic cholecystectomy is helpful for the confirmation of suspicious cases.

Prospective Study of a Protocol for Selection of Treatment of Acute Pancreatitis Based on Scoring of Severity

Background/Aim: Since July 1994, we have been conducting a prospective study of a protocol for selection of treatment of acute pancreatitis based on scoring of severity. Methods: From July 1994 to June 1998, 56 patients with acute pancreatitis were enrolled in this study. The protocol employed was based on the results of our retrospective study. On admission, the prognosis score (scoring of severity of acute pancreatitis based on the criteria of the Ministry of Health and Welfare of Japan) and APACHE II score were calculated, and early treatment was selected according to the protocol. Results: All of the 26 patients with gallstone pancreatitis and 28 of 30 patients with non-gallstone pancreatitis were successfully treated and had good outcome. There were 2 deaths in non-gallstone pancreatitis. In selection of early treatment according to the scoring of severity, we suggested that when the prognosis score is 2 or more and the APACHE II score of 8 or more, gallstone pancreatitis should be treated by biliary drainage, and non-gallstone pancreatitis by peritoneal lavage. When infected pancreatic necrosis is exhibited, surgery is indicated. Conclusion: Our new management protocol for acute pancreatitis based on the prognosis score and APACHE II score appear to be useful for accurately scoring severity and selecting the treatment methods.

Extended Pancreatic Resection for Carcinoma of the Pancreas

The frequency of occurrence of cancer of the pancreas has been steadily increasing in both sexes in Japan, as in Western countries, and pancreatic carcinoma is now the fourth leading cause of cancer deaths in Japan.