Toshifumi Matsumoto

Optimal management of the branch duct type intraductal papillary mucinous neoplasms of the pancreas.

Goals To determine the optimal management of the intraductal papillary mucinous neoplasms (IPMNs) according to the morphologic type based on distinguishing between benign and malignant diseases. Backgrounds IPMNs are increasingly recognized clinicopathologic entity. Extended pancreatic resection with radical lymph node dissection has been recommended for treatment. Study A retrospective clinicopathologic study was carried out of the 57 cases with IPMNs who were treated between 1985 and 2001. Forty-three patients with IPMNs underwent resection, and 14 patients with small IPMNs were observed without resection. Results Among the 43 resected IPMNs, 25 were benign and 18 were malignant. Malignant tumors were significantly greater in diameter than benign tumors (52.9 vs. 30.2 mm, P < 0.05). All main duct type tumors with mural nodules were malignant. All branch duct type tumors less than 30 mm in diameter and without mural nodules were benign. Twelve branch duct type IPMNs size less than 30 mm were not resected and have not progressed. Conclusion These results suggest that the branch duct type IPMNs less than 30 mm and without mural nodules is benign and might be treatable with limited resection or careful observation.

Laparoscopic distal pancreatectomy and open distal pancreatectomy: a nonrandomized comparative study.

Although laparoscopic distal pancreatectomy (LDP) is technically feasible, its benefits remain uncertain. The purpose of this study was to compare the clinical results of LDP and open distal pancreatectomy (ODP). The medical records of 14 consecutive patients who underwent LDP were reviewed and compared with those of 19 patients who underwent ODP. All patients were treated for benign or borderline malignant disease of the pancreas. Operation time was longer for LDP than for ODP (290.7 vs. 213.8 min, P=0.0022), and postoperative analgesics were administered less frequently for patients who underwent LDP. Patients treated by LDP had earlier recovery of bowel function, shorter time to oral intake, and shorter postoperative hospital stay than those treated by ODP. No difference in morbidity or inflammatory response was observed between the 2 groups. LDP for benign or borderline malignant disease of the pancreas provides benefits without increasing morbidity.

Comparison of pneumoperitoneum and abdominal wall lifting as to hemodynamics and surgical stress response during laparoscopic cholecystectomy

AbstractBackground: Impairments in hemodynamics during pneumoperitoneum (PP) have been noted. This study compared changes in hemodynamics and surgical stress response with PP and abdominal wall lifting (AWL) during laparoscopic cholecystectomy. Methods: Twenty patients with symptomatic cholecystolithiasis were assigned to PP (n= 10) or AWL (n= 10). Cardiac output (CO), stroke volume (SV), and ejection fraction (%EF) were measured by transesophageal echocardiography. Clearances of para-aminohippurate (CPAH) and sodium thiosulfate (CSTS) were determined as measures of renal function. Levels of interleukin-6, C-reactive protein, white cell count, and neutrophil elastase were evaluated as indicators of surgical stress. Results: In the PP group, CO, SV, and %EF were depressed significantly during pneumoperitoneum. Immediately after and 15 min after insufflation, the CPAH and CSTS were decreased by 78.0% and 73.8%, respectively. None of the hemodynamic parameters changed significantly in the AWL group. Surgical stress response was not different significantly between the two groups. Conclusions: In contrast to pneumoperitoneum, AWL did not alter cardiac function or renal hemodynamics. AWL may be useful in patients with cardiovascular or renal disorders.

Improved long-term survival after liver resection for hepatocellular carcinoma in the modern era: retrospective study from HCV-endemic areas.

It remains unclear whether recent progress in perioperative management and treatment for recurrent hepatocellular carcinoma (HCC) has improved patient outcomes in hepatitis C virus-endemic areas. The clinicopathologic and follow-up data of 218 consecutive HCC patients who underwent curative resection between 1982 and 2003 were analyzed. Patients were assigned to one of two groups: before 1992 (early group; n = 82) and 1992 and later (late group; n = 136). Factors influencing survival rates were investigated by multivariate analysis. The effects of the period during which the hepatic resection was done on the patients’ outcome were examined with respect to tumor size. The 5-year cancer-related and disease-free survival rates were 51.4% and 20.4%, respectively. The late group showed better 5-year cancer-related survival than the early group (64.1% vs. 33.8%), but disease-free survival did not differ significantly between the groups. On multivariate analysis, the period of the hepatic resection was identified as an independent prognostic factor for cancer-related survival (relative risk 0.70, P < 0.01) but not disease-free survival. There were no differences in the cancer-related and disease-free survival rates between the two groups for patients with tumors ≤ 25 mm. In patients with HCCs > 50 mm, both cancer-related and disease-free survival rates were better in patients in the late group. During the past two decades, improvements in the treatment of recurrent HCC tumors have contributed to controlling large HCCs but not to controlling the multicentric development of HCCs. It may be important to control multicentric recurrence of HCC to improve patient survival in areas where the hepatitis C virus is endemic.

Analysis of preoperative prognostic factors for long-term survival after hepatic resection of liver metastasis of colorectal carcinoma.

Hepatic resection is the most effective therapy for liver metastasis of colorectal carcinoma. To clarify indications for this therapy, the clinicopathologic and follow-up data of 103 consecutive patients who underwent hepatic resection for metastases of colorectal carcinoma were analyzed. Factors influencing overall survival rate were investigated by multivariate analysis. Thereafter, patients who underwent resection were stratified according to the number of independent risk factors present, and their outcomes were compared with those of 14 nonresection patients with fewer than six liver tumors and without extrahepatic metastasis. The overall survival rate of the 103 resection patients was 43.1%. The clinicopathologic factors shown to affect on long-term survival after hepatic resection were the interval between colorectal and hepatic surgery (<12 months), preoperative carcinoembryonic antigen level (>-10 ng/ml), and number of hepatic metastases (four or more). The 5-year overall survival rates were 75.0% with no risk factors (n = 16), 53.6% with one risk factor (n = 46), 23.0% with two risk factors (n = 36), and0%with three risk factors (n = 5). Survival rates did not differ between resection patients with three risk factors and nonresection patients. Therefore, hepatic resection may be appropriate for patients with fewer than three risk factors.

Factors predicting recurrence after resection of pancreatic ductal carcinoma.

Objective: Pancreatic ductal carcinoma frequently recurs postoperatively, and we analyzed clinicopathological features of patients treated by surgical resection to find predictors of postoperative recurrence. Methods: A retrospective cohort study was performed that included 69 patients between 1985 and 2003. Clinicopathologic factors were evaluated for tumor recurrences by univariate and multivariate analyses. Results: Mean survival time and actuarial 5-year disease-specific survival were significantly lower in cases of hepatic metastasis (13 months, 0%) and in cases of peritoneal carcinomatosis (15 months, 6.8%) than in cases of local retroperitoneal recurrence (30 months, 21%). Univariate and logistic regression analyses showed undifferentiated adenocarcinoma to be independently associated with hepatic metastasis (odds ratio, 7.4; 95% confidence interval, 1.5-37.0) and invasion of the portal vein to be independently associated with peritoneal carcinomatosis (odds ratio, 4.0; 95% confidence interval, 1.2-12.8). Multivariate analysis showed undifferentiated adenocarcinoma, invasion of the anterior capsule, and invasion of the portal vein to be independent prognostic factors. Conclusion: Undifferentiated adenocarcinoma and invasion of the portal vein are predictors of poor outcome and are related to hepatic metastasis and peritoneal carcinomatosis, respectively. Postoperative adjuvant chemotherapy, including intra-arterial chemotherapy, should be selected according to prediction of the patterns of recurrence.

Chemokine receptor CCR6 as a prognostic factor after hepatic resection for hepatocellular carcinoma.

Background and Aims:  Chemokines and their receptors have recently been shown to have major roles in cancer metastasis. The aim of this study was to determine whether the interaction between chemokine receptor 6 (CCR6) and its ligand, macrophage inflammatory protein‐3 alpha (MIP‐3α), correlates with metastasis of hepatocellular carcinoma (HCC).

Laparoscopic cholecystectomy in the treatment of patients with gallbladder cancer

BACKGROUND Surgical procedures based on the depth of the primary tumor invasion (pT category) have been proposed in the treatment of gallbladder cancer (GBC). Trocar site metastases have been reported in patients who underwent laparoscopic cholecystectomy (LC) for preoperatively undiagnosed GBC. STUDY DESIGN The aim of this study was to clarify the role of LC as a surgical strategy for GBC. From 1986 to 1998, 56 patients with GBC underwent surgical resection. Survival rates were compared retrospectively according to pT category and use of LC. RESULTS Five-year survival was 91% for pT1 (n = 13), 64% for pT2 (n = 25), 34% for pT3 (n = 14), and 0% for pT4 tumors (n = 4; p<0.0001). LC was performed on 11 patients (4 with pT1, 5 with pT2, and 2 with pT3 tumors). Of the seven patients with pT2 or pT3 tumors, three underwent a second radical operation, three had an open radical operation to which the procedure was converted from LC, and one underwent no additional procedures. For pT1 tumors, one patient died of trocar site metastasis from bile spillage after LC. For pT2 or pT3 tumors, 5-year survival was 63% for radical surgery (n = 35) and 0% for cholecystectomy alone (n = 4; p<0.05). For pT2 or pT3 tumors treated by radical surgery, 5-year survival was 75% for laparoscopic approach (n = 6) and 60% for open surgery (n = 29; not significant). CONCLUSIONS LC may help to establish the diagnosis and to determine the surgical strategy for undiagnosed GBC. It is important to prevent spillage or implantation of malignant cells during LC. For pT2 or pT3 tumors diagnosed laparoscopically, a second or converted open radical surgery is necessary.

Ethanol injection therapy of an isolated bile duct associated with a biliary‐cutaneous fistula

Abstract  Bile leakage after hepatic resection often results in the formation of a biliary‐cutaneous fistula. Such a fistula, when caused by an isolated bile duct in the remnant liver, can be intractable. We report a successful case of ethanol injection therapy of an isolated bile duct. A 73‐year‐old man underwent right hepatic resection for hepatocellular carcinoma. Bile leakage occurred after surgery, and the patient developed a biliary‐cutaneous fistula. Fistulography revealed an isolated bile duct in the remnant portion of the caudate lobe without communication to the main biliary system. As conservative management with simple drainage was ineffective, injection therapy with ethanol was performed with a balloon occlusion catheter. After 11 therapy sessions, the bile duct was eradicated, and the biliary‐ cutaneous fistula was completely healed. The post‐treatment course was uneventful. Ethanol injection therapy can be a choice for management of patients with a biliary fistula caused by an isolated bile duct.

Laparoscopic resection of a pancreatic mucinous cystadenoma using laparosonic coagulating shears

Abstract. A 71-year-old woman with a solitary mucinous cystic neoplasm of the pancreatic tail complained of back pain. A laproscopic distal pancreatectomy was performed. Laparosonic coagulating shears (LCS) were employed for dissection of the surrounding tissue and transection of the pancreas. The main pancreatic duct was clipped. There was no evidence of bleeding or pancreatic leakage from the transection surface. Pathologic examination showed the tumor to be a mucinous cystadenoma. The postoperative course was uneventful. The LCS was effective in this application.