Yamaguchi K

Laparoscopic pancreatic surgery: Current indications and surgical results

Background: Although minimally invasive surgery has achieved worldwide acceptance in various fields, laparoscopic surgery for pancreatic diseases has been reported only rarely. The purpose of this study was to evaluate the outcomes and feasibility of laparoscopic pancreatic surgery. Methods: Fifteen patients, comprising eight men and seven women with an average age of 54 years, underwent laparoscopic pancreatic surgery. Distal pancreatectomy was indicated for solid tumors (n = 4), cystic lesions (n = 3), and chronic pancreatitis (n = 2). Cystogastrostomy was performed for pseudocysts (n = 4) and enucleation for insulinomas (n = 2). The lesions varied in size from 1 to 9 cm (2.9 ± 2.4 cm) and were located in the pancreatic head (n = 2), body (n = 3), or tail (n = 10). For distal pancreatectomy, the splenic artery was divided and the parenchyma was transected with a linear stapler. Laparoscopic ultrasonography was used to determine the distance between the tumor and the main pancreatic duct for enucleation as well as to localize the lesion for distal pancreatectomy. Cystogastrostomy, 4.5 cm in length, was also performed with the linear stapler through the window of the lesser omentum. Results: Mean operation time was 249 ± 70 min (293 ± 58 min in distal pancreatectomy, 185 ± 14 min in enucleation, 204 ± 50 min in cystogastrostomy), and mean blood loss was 138 ± 184 g (213 ± 227 g, 75 ± 35 g, 38 ± 48 g, respectively). Two distal pancreatectomies (13%) were converted to open surgery due to severe peripancreatic inflammation. There was no related mortality, but there were two cases (15%) of pancreatic fistula, one in a distal pancreatectomy case and the other in an enucleation case, and both were treated conservatively. Conclusions: Laparoscopic pancreatic surgery is safe and feasible for patients with benign tumors and cystic lesions.

Hepatolithiasis associated with cholangiocarcinoma. Possible etiologic significance

Three cases of primary bile duct carcinomas (cholangiocarcinomas) were found among 61 cases of hepatolithiasis. Cholangiocarcinoma arose from the extrahepatic bile duct in one and from the dilated intrahepatic bile duct in two patients. Hyperplasia of the columnar cells was often present. These hyperplastic epithelial cells often show papillomatous or adenomatous pattern, which are frequently associated with the presence of stones and the contaminated bile, and may show malignant changes leading to the development of cholangiocarcinoma.

Laparoscopically assisted resection of choledochal cyst and Roux-en-Y reconstruction

Laparoscopic surgery for a congenital choledochal cyst was accomplished in five of eight adult patients for whom it was attempted (63%). Creation of a Roux-en-Y jejunal limb by midline minilaparotomy and hepaticojejunostomy using a laparoscopic sewing instrument facilitated the procedure. Background: Congenital choledochal cyst is a good indication for laparoscopic surgery. However, only two case reports are available at this writing. Methods: Eight adult patients, ages 19 to 61 years (mean, 32.6 years), underwent laparoscopically assisted resection of the choledochal cyst and Roux-en-Y hepaticojejunostomy. Results: The whole procedure was accomplished in five patients (63%). The duration of the procedure ranged from 525 to 680 min (average, 616 min). Open conversion in three patients was necessitated by severance of a small common hepatic duct because of disorientation caused by previous laparoscopic cholecystectomy, electrocautery injury to the common channel distal to the anomalous pancreaticobiliary junction, or heavy adhesion around the cyst secondary to recent severe cholangitis. Creation of a Roux-en-Y jejunal limb by midline minilaparotomy and hepaticojejunostomy using a laparoscopic sewing instrument facilitated the procedure. Conclusions: Laparoscopically assisted resection of the choledochal cyst and hepaticojejunostomy are technically feasible and deserve further clinical trials.

Pancreatic head resection with and without preservation of the duodenum : Different postoperative gastric motility

BACKGROUND Early gastric stasis is a unique complication of pylorus-preserving pancreatoduodenectomy. Because the duodenum proved to be important in the initiation and consolidation of phase III activity of the migrating motor complex of the stomach, the absence of the duodenum and hence gastric phase III may be a cause of gastric stasis. METHODS Postoperative gastrointestinal motility was measured with a pneumohydraulic capillary infusion system in nine patients who had undergone pylorus-preserving pancreatoduodenectomy through an indwelling tube assembly placed at operation, and compared with that in six patients who had undergone duodenum-preserving pancreatic head resection. Plasma motilin concentrations were measured by radioimmunoassay. RESULTS The mean period until the first occurrence of gastric phase III was significantly longer in patients who had undergone a pylorus-preserving pancreatoduodenectomy (40.6 +/- 4.6 days or more) than in patients who had undergone a duodenum-preserving pancreatic head resection (18.8 +/- 4.3 days; p < 0.05). On the day of the first observation of gastric phase III, the plasma concentration of motilin at proximal jejunal phase III in patients who underwent a pylorus-preserving pancreatoduodenectomy (50.2 +/- 9.8 pg/ml) was significantly lower than that at duodenal phase III in patients who underwent a duodenum-preserving pancreatic head resection (184.6 +/- 48.6 pg/ml; p < 0.05). CONCLUSIONS Gastric stasis after a pylorus-preserving pancreatoduodenectomy may be in part attributable to the low concentration of plasma motilin caused by the resection of the duodenum.

Sonic hedgehog is an early developmental marker of intraductal papillary mucinous neoplasms: clinical implications of mRNA levels in pancreatic juice.

Intraductal papillary mucinous neoplasms (IPMNs) are common cystic tumours of the pancreas. Sonic hedgehog (SHH) is involved in gastric epithelial differentiation and pancreatic carcinogenesis. However, a comprehensive analysis of SHH expression in IPMN has not yet been performed. In the present study, one‐step quantitative real‐time reverse transcription‐polymerase chain reaction with gene‐specific priming was used to examine mRNA levels in various types of clinical samples. SHH expression in IPMN was measured and the possible association of gastric epithelial differentiation with development of IPMN was evaluated. In bulk tissue analyses (IPMNs, 11 pancreatic cancer, and 20 normal pancreatic tissues), IPMN expressed significantly higher levels of SHH than did normal pancreas (IPMN versus normal pancreas, p = 0.0025; pancreatic cancer versus normal pancreas, p = 0.0132), but SHH expression did not differ between IPMN and pancreatic cancer (p = 0.3409). In microdissection analyses (infiltrating ductal carcinoma cells from 20 sections, IPMN cells from 20 sections, pancreatitis‐affected epithelial cells from 11 sections, and normal epithelial cells from 12 sections), IPMN cells expressed significantly higher levels of SHH than did cancer cells, normal cells, or pancreatitis‐affected ductal cells (all comparisons, p < 0.008). Pancreatic juice analyses (20 samples from pancreatic cancers, 31 samples from IPMNs, and 27 samples from chronic pancreatitis) revealed that SHH expression differed significantly between IPMN juice and pancreatitis juice (p < 0.0001), and between cancer juice and pancreatitis juice (p = 0.0125). Receiver operating characteristic curve analyses revealed that SHH measurement in pancreatic juice was useful for discriminating IPMN from chronic pancreatitis (area under the curve = 0.915; 95% confidence interval: 0.796–0.976). The data suggest that overexpression of SHH is an early event in the development of IPMN and that SHH measurement in pancreatic juice may provide some advantages for the treatment or follow‐up of a subset of patients with IPMN or chronic pancreatitis. Copyright

Over-expression of S100A2 in pancreatic cancer correlates with progression and poor prognosis.

Controversy exists regarding the clinical significance of S100A2 in the progression of tumours. In pancreatic cancer, little is known about the role of S100A2. The aim of this study was to clarify the clinical significance of S100A2 expression in pancreatic carcinogenesis. We microdissected invasive ductal carcinoma (IDC) cells from 22 lesions, pancreatic intraepithelial neoplasia (PanIN) cells from five lesions, intraductal papillary mucinous neoplasm (IPMN) cells from 38 lesions, pancreatitis‐affected epithelial (PAE) cells from 16 lesions, and normal ductal cells from 18 normal pancreatic tissues. S100A2 expression in 14 pancreatic cancer cell lines, microdissected cells and formalin‐fixed paraffin‐embedded (FFPE) samples was examined by quantitative reverse transcription‐polymerase chain reaction (qRT–PCR). Microdissection analyses revealed that IDC cells expressed higher levels of S100A2 than did IPMN, PAE or normal cells (all comparisons, p < 0.007). Cell lines from metastatic sites expressed higher levels of S100A2 than those from primary sites. PanIN cells expressed higher levels of S100A2 than normal cells (p = 0.018). IDC cells associated with poorly differentiated adenocarcinoma expressed higher levels of S100A2 than did IDC cells without poorly differentiated adenocarcinoma (p = 0.006). Analyses of FFPE samples revealed that levels of S100A2 were higher in samples from patients who survived < 1000 days after surgery than in those from patients who survived > 1000 days (p = 0.043). Immunohistochemical analysis was consistent with qRT–PCR. S100A2 may be a marker of tumour progression or prognosis in pancreatic carcinogenesis and pancreatic cancer. Copyright

Pleomorphic carcinoma of the pancreas: Reappraisal of surgical resection

Pleomorphic carcinoma is a rare variant of pancreatic exocrine carcinoma. The aim of this communication is to reappraise surgical resection of pleomorphic carcinoma of the pancreas. Clinicopathological findings of four Japanese patients with pleomorphic carcinoma of the pancreas were reviewed and compared with those of 24 Japanese patients with adenocarcinoma of the pancreas to clarify possible surgical implications of pleomorphic carcinoma. Of the four patients, three were female and one male, aged 64, 65, 66, and 74 yr, respectively. Two carcinomas were located in the head of the pancreas, one in the body, and the other in the tail. Ultrasonography demonstrated a well defined hypoechoic mass measuring 5–10 cm, with central necrotic area in all of the patients. Computed tomography showed a low density tumor with sharp margin and heterogenous internal structure in all. On angiography, three tumors were hypervascular and another was hypovascular. Extensive vascular encasement was observed in all. Pancreatoduodenectomy was done in two patients and distal pancreatectomy in the other two. Multiple liver metastases occurred 1 month after surgical resection in two patients and local recurrence 1 month in one and 2 months in the other, leading to death either 2 (2 patients) or 3 months (2 patients) after pancreatectomy. Significantly differentiating features of the four pleomorphic carcinomas of the pancreas and the 24 adenocarcinomas of the pancreas were the mean diameter (6.6 ± 1.3 cm vs 3.5 ± 0.3 cm, p= 0.0007), margin of the tumor (expansive in the four pleomorphic carcinomas versus infiltrative in 21 of the 24 adenocarcinomas, p= 0.003) and vascularity on angiography (hypervascular in three of the four pleomorphic carcinomas versus hypovascular in 21 of the 23 adenocarcinomas, p= 0.013). The 1-yr and 3-yr survival rates of the four patients with pleomorphic carcinoma were 0% and 0%, whereas those of the 24 patients with adenocarcinoma of the pancreas were 42% and 13%, respectively (p < 0.0001). These findings suggest that the clinical course of patients with pleomorphic carcinoma of the pancreas is so poor even after surgical resection that pleomorphic carcinoma of the pancreas is not a candidate for pancreatectomy despite its locally expansive growth.