Tatsuya Yoshikawa

Does gross appearance indicate prognosis in intrahepatic cholangiocarcinoma

Survival after surgery for intrahepatic cholangiocarcinoma (ICC) is usually poor. The objective of this study was to investigate whether the gross appearance of ICC indicates postoperative prognosis.

Preoperative biliary drainage for biliary tract and ampullary carcinomas

We posed six clinical questions (CQ) on preoperative biliary drainage and organized all pertinent evidence regarding these questions. CQ 1. Is preoperative biliary drainage necessary for patients with jaundice? The indications for preoperative drainage for jaundiced patients are changing greatly. Many reports state that, excluding conditions such as cholangitis and liver dysfunction, biliary drainage is not necessary before pancreatoduodenectomy or less invasive surgery. However, the morbidity and mortality of extended hepatectomy for biliary cancer is still high, and the most common cause of death is hepatic failure; therefore, preoperative biliary drainage is desirable in patients who are to undergo extended hepatectomy. CQ 2. What procedures are appropriate for preoperative biliary drainage? There are three methods of biliary drainage: percutaneous transhepatic biliary drainage (PTBD), endoscopic nasobiliary drainage (ENBD) or endoscopic retrograde biliary drainage (ERBD), and surgical drainage. ERBD is an internal drainage method, and PTBD and ENBD are external methods. However, there are no reports of comparisons of preoperative biliary drainage methods using randomized controlled trials (RCTs). Thus, at this point, a method should be used that can be safely performed with the equipment and techniques available at each facility. CQ 3. Which is better, unilateral or bilateral biliary drainage, in malignant hilar obstruction? Unilateral biliary drainage of the future remnant hepatic lobe is usually enough even when intrahepatic bile ducts are separated into multiple units due to hilar malignancy. Bilateral biliary drainage should be considered in the following cases: those in which the operative procedure is difficult to determine before biliary drainage; those in which cholangitis has developed after unilateral drainage; and those in which the decrease in serum bilirubin after unilateral drainage is very slow. CQ 4. What is the best treatment for postdrainage fever? The most likely cause of high fever in patients with biliary drainage is cholangitis due to problems with the existing drainage catheter or segmental cholangitis if an undrained segment is left. In the latter case, urgent drainage is required. CQ 5. Is bile culture necessary in patients with biliary drainage who are to undergo surgery? Monitoring of bile cultures is necessary for patients with biliary drainage to determine the appropriate use of antibiotics during the perioperative period. CQ 6. Is bile replacement useful for patients with external biliary drainage? Maintenance of the enterohepatic bile circulation is vitally important. Thus, preoperative bile replacement in patients with external biliary drainage is very likely to be effective when highly invasive surgery (e.g., extended hepatectomy for hilar cholangiocarcinoma) is planned.

Differential diagnosis of polypoid lesions of the gallbladder by endoscopic ultrasonography

BACKGROUND Transabdominal ultrasonography (US) has made the detection of gallbladder polyps easier, but the differential diagnosis of polyps less than 20 mm remains difficult. Therefore, we evaluated the usefulness of endoscopic ultrasonography (EUS) for the differential diagnosis of gallbladder polyps. METHODS Among patients with gallbladder polyps less than 20 mm, we reviewed 89 patients who underwent US and EUS before surgery and assessed the results of differential diagnoses by them. RESULTS In all, 86.5% of these polyps were precisely diagnosed by EUS. However, only 51.7% were diagnosed by US. Sensitivity, specificity, and positive and negative predictive values of EUS at the diagnosis of carcinoma were 91.7%, 87.7%, 75.9%, and 96.6%, respectively. Those of US were 54.2%, 53.8%, 54.2%, and 94.6%, respectively. CONCLUSIONS EUS may markedly improve the accuracy of the differential diagnosis of gallbladder polyps. Therefore, EUS is thought to play an important role in determining the treatment strategy for gallbladder polyps.

Should the Extrahepatic Bile Duct be Resected or Preserved in R0 Radical Surgery for Advanced Gallbladder Carcinoma? Results of a Japanese Society of Biliary Surgery Survey: A Multicenter Study

PurposeWe assessed the significance of an extra bile duct resection by comparing the survival of patients with advanced gallbladder carcinoma who had resected bile ducts with those who had preserved bile ducts. A radical cholecystectomy that includes extra bile duct resections has been performed without any clear evidence of whether an extra bile duct resection is preventive or curative.MethodsWe conducted a questionnaire survey among clinicians who belonged to the 114 member institutions of the Japanese Society of Biliary Surgery. The questionnaires included questions on the preoperative diagnosis, complications, treatment, and surgical treatment, resection procedures, surgical results, pathological and histological findings, mode and site of recurrence, and the need for additional postoperative treatment. A total of 4243 patients who had gallbladder carcinoma and were treated from January 1, 1994 to December 31, 2003 were identified. The 838 R0 patients with pT2, pT3, and pT4 advanced carcinoma of the gallbladder for which there was no cancer invasion to the hepatoduodenal ligament or cystic duct in the final analysis.ResultsThe 5-year cumulative survival, postoperative complications, postoperative lymph node metastasis, and local recurrence along the hepatoduodenal ligament were not substantially different between the resected bile duct and the preserved bile duct groups.ConclusionsOur retrospective questionnaire survey showed that an extrahepatic bile duct resection had no preventive value in some patients with advanced gallbladder carcinoma in comparison to similar patients who had no such bile duct resection. An extrahepatic bile duct resection may therefore be unnecessary in advanced gallbladder carcinoma without a direct infiltration of the hepatoduodenal ligament and the cystic duct.

Hepatic resection in 485 R0 pT2 and pT3 cases of advanced carcinoma of the gallbladder: results of a Japanese Society of Biliary Surgery survey—a multicenter study

PURPOSE We conducted this study to evaluate the optimal hepatic resection for pT2 and pT3 advanced carcinoma of the gallbladder without invasion of the hepatoduodenal ligament. METHODS We conducted a questionnaire survey regarding 4,243 cases of carcinoma of the gallbladder treated during the recent 10-year period at 112 institutions belonging to the Japanese Society of Biliary Surgery. The questionnaires included questions on preoperative-diagnosis, complications, treatment, and surgical treatment, procedures of resection, surgical result, path histological findings, mode, and site of recurrence, additional post-operative treatment. They included 293 pT2 and 192 pT3 R0 cases, which were negative for hepatoduodenal ligament invasion, and the cumulative survival rates and sites of postoperative recurrence in the form of liver metastasis, were retrospectively analyzed in these 485 cases. RESULT There were no significant differences in survival rate or recurrence rates in the form of liver metastasis between the groups that underwent resection of the gallbladder bed, the group that underwent segmentectomy 4a+5, and the group that underwent hepatectomy in patients with of both pT2 or pT3 gallbladder cancers. Our results also did not show that liver metastasis to segment 4a5 alone was particularly common. CONCLUSION For gallbladder cancer, neither with hepatoduodenal ligament invasion nor hepatic invasion, resection of the gallbladder bed is more preferable for surgical hepatic procedure. For gallbladder cancer that invades any hepatic sites, a hepatic surgical procedure that could eliminate surgical margins would be desirable.

Intraoperative evaluation of the depth of invasion of gallbladder cancer

BACKGROUND It is sometimes very difficult to diagnose the depth of invasion of gallbladder cancer preoperatively. Therefore, we investigated intraoperative examinations to diagnose the depth of invasion. METHODS A total of 104 patients were included in this study. The relation between macroscopic morphology and the depth of invasion and evaluation of the depth of invasion by intraoperative ultrasonography and frozen section examination were investigated. RESULTS In all cases of a pedunculated type and a subpedunculated type with thin base, invasion remained within the mucosa. In other types, the depth of invasion was various. The accuracy of diagnosing the depth of invasion by intraoperative ultrasonography and frozen section examination was 73.9% and 85.7%, respectively. CONCLUSIONS The cancer classified as a pedunculated type or a subpedunculated type with thin base can be diagnosed to remain within the mucosa. In other types, intraoperative ultrasonography and frozen section examination are useful in the diagnosis of the depth of invasion.

The Significance of Hepatectomy for Primary Intrahepatic Stones

The objective of this study was to evaluate the significance of performing hepatectomy for primary intrahepatic stones. Observations on the morphology of the bile ducts, histopathological findings of the excised liver, and treatment results were reviewed in 29 of 35 patients with primary intrahepatic stones. The remaining 6 patients (17.1%) were excluded because they had intrahepatic cholangiocarcinoma. The subjects were classified into two groups according to the morphological characteristics of the bile ducts; one group comprised 25 patients having strictures in the central bile duct, and another group comprised 4 patients having no biliary stricture, but a localized dilatation in the distal bile duct. Calcium bilirubinate stones were found in all the patients with a biliary stricture, whereas cholesterol stones were found in those without a biliary stricture. Hepatectomy was performed in 25 of the 29 patients (86.2%), the results of which were excellent. In fact, during the past 10 years, no postoperative complications have occurred, nor have there been any retained or recurrent stones. Moreover, the postoperative hospitalization period was as short as 15.3 days. The findings of this study indicate that hepatectomy allows treatment for primary intrahepatic stones to be completed within a short period of time without incurring serious postoperative complications, and serves as a useful prophylactic technique for recurrent stones.

Nine-year patency of a vascular prosthesis used for portal vein reconstruction during pancreatoduodenectomy

We report a patient in whom a polytetrafluoroethylene (PTFE) graft used for reconstruction of the portal vein was confirmed to be patent 9 years after pancreatoduodenectomy (which was performed when he was aged 51 years). The patient had advanced cancer of the head of the pancreas. Pancreatoduodenectomy was performed, and 6 cm of the portal vein was resected. The portal vein was reconstructed with a PTFE graft (internal diameter 9 mm; length about 6 cm). The graft was demonstrated to be patent on angiography 3 years after the operation. A computed tomographic (CT) scan performed 9 years after the operation showed that the portal graft was still patent. About 2 years after the operation, the patient had been able to resume physical labor, similar to the work he performed before the operation.

Hepatoligamentopancreatoduodenectomy in Patients with Advanced Gallbladder Carcinoma

Advanced carcinomas of the gallbladder often involve the hepatoduodenal ligament and have a poor prognosis. Dissection of the hepatoduodenal ligament with preservation of the portal vein and hepatic artery has a high risk of residual tumor and early death. Curative resection in patients with invasion of the hepatoduodenal ligament ideally requires en bloc resection of the entire ligament. F. Hanyu of our department has developed an extended procedure, referred to as hepatoligamentopancreatoduodenectomy (HLPD), for en bloc resection of the right lobe of the liver and head of the pancreas with the hepatoduodenal ligament. This chapter describes the surgical technique of HLPD and outlines the background of its development as well as its indications, long-term outcome, and problems. Curative resection could be performed in all patients using HLPD; however, long-term survival could not be determined and operative mortality was extremely high, thus the clinical significance of HLPD was not established. We concluded that the clinical significance of HLPD for patients with advanced gallbladder carcinoma with hepatoduodenal ligament invasion should be evaluated after the safety of the procedure has been established and the cumulative results of a number of cases have been obtained.

Ultrasonographic Diagnosis of Anomalous Arrangement of the Pancreaticobiliary Ductal System without Dilatation of the Common Bile Duct.

超音波検査による胆管非拡張型膵・胆管合流異常の診断について検討した. 対象は胆管非拡張型膵・胆管合流異常38例のうち癌併存例を除いた18例である. USでは12例中9例で胆嚢壁が2層または3層構造を呈し, 最内側層が主に肥厚し, 表面に凹凸を認めた. 切除胆嚢の病理組織学的検索から, 本所見は粘膜の過形成を表している可能性が高いと推測された. 合流異常のない対照群20例では, このような所見は認められなかったことから, 本所見の有無によりスクリーニング検査を行うことで, USによる胆管非拡張型膵・胆管合流異常の効率の良い拾い上げが可能になると考えられた. EUS像はUS像よりも鮮明で, 11例中9例ではUSと同様の所見が容易に認識でき, 7例では合流部も描出できた. したがって, USで今回確認された特徴的所見が認められた場合には, EUSを施行することが必要であり, 胆嚢壁における変化から膵. 胆管合流異常が疑わしい場合には積極的にERCPまで行うべきである.