Yasuro Futagawa

Single‐incision laparoscopic distal pancreatectomy with or without splenic preservation: How we do it

Recent interest in improving cosmetic outcomes has led to single‐incision laparoscopic surgery (SILS) being performed in a variety of organs. However, this innovative technique has rarely been introduced in pancreatic surgery, as it is considered to be a challenging procedure. We report herein our technique of single‐incision laparoscopic distal pancreatectomy with or without splenic preservation.

Preoperative platelet to lymphocyte ratio predicts outcome of patients with pancreatic ductal adenocarcinoma after pancreatic resection

BACKGROUND Inflammation plays a crucial role in tumor growth, metastasis, and survival. The preoperative platelet-to-lymphocyte ratio (PLR) has been reported as a significant prognostic indicators in several digestive malignancies. Our objective was to evaluate whether preoperative PLR is a prognostic index in resected pancreatic ductal adenocarcinoma. METHODS Data from 131 patients who underwent pancreatic resection for pancreatic ductal adenocarcinoma were available from a prospectively maintained database. The patients were divided into groups according to a preoperative PLR of <150 or ≥150. Survival data were analyzed. RESULTS In univariate and multivariate analyses, a preoperative PLR of ≥150 was a significant and independent risk factor for cancer recurrence and poor survival, respectively (disease-free survival [DFS]; P= .0014, P = .047; OS, P ≤ .01each). Similarly, lymph node metastasis, and moderate or poor differentiation were independent risk factors for cancer recurrence, whereas tumor diameter, positive surgical margin, and moderate or poor differentiation were independent risk factors for poor patient survival (P ≤ .05 each). CONCLUSION The preoperative PLR in patients with pancreatic ductal adenocarcinoma was an independent predictor in DFS and overall survival after elective resection. Measurement of the PLR may help decision making in the postoperative management of patients with pancreatic ductal adenocarcinoma.

Efficient and cancer-selective gene transfer to hepatocellular carcinoma in a rat using adenovirus vector with iodized oil esters.

Gene therapy for cancer requires efficient, selective gene transfer to cancer cells. In gene therapy for hepatocellular carcinoma (HCC), gene transfer is efficient for small tumors, but not for large tumors. The delivery of anticancer agents and of iodized oil esters as embolic agents through tumor-feeding arteries is known as transarterial embolization. We speculate that genes may be efficiently and selectively transferred for HCC using iodized oil esters because these esters may remain together with a genetic vector within HCC selectively. Hence, we have studied the effect of iodized oil esters on adenovirus vector–mediated gene transfer for HCC in vivo. A rat model of HCC induced with diethylnitrosamine and phenobarbital was injected with either AxCALacZ, which expresses the β-galactosidase of Escherichia coli , or AxCALacZ and iodized oil esters into the hepatic artery. Histological comparisons revealed that the β-galactosidase expression in the rats with HCC injected with AxCALacZ and iodized oil esters was greater ( P <.0001) in small tumors ( P =.0046) and large tumors ( P =.0023), and more selective ( P =.0229) than in only AxCALacZ-injected rats. These results suggest that iodized oil esters are injected into hepatic artery together with adenovirus vector, and that genes may be efficiently and cancer-selectively transferred to HCC. Cancer Gene Therapy (2001) 8, 713–718

Utility of augmented reality system in hepatobiliary surgery

Background/purposeThe aim of this study was to evaluate the utility of an image display system for augmented reality in hepatobiliary surgery under laparotomy.MethodsAn overlay display of organs, vessels, or tumor was obtained using a video see-through system as a display system developed at our institute. Registration between visceral organs and the surface-rendering image reconstructed by preoperative computed tomography (CT) was carried out with an optical location sensor. Using this system, we performed laparotomy for a patient with benign biliary stricture, a patient with gallbladder carcinoma, and a patient with hepatocellular carcinoma.ResultsThe operative procedures performed consisted of choledochojejunostomy, right hepatectomy, and microwave coagulation therapy. All the operations were carried out safely using images of the site of tumor, preserved organs, and resection aspect overlaid onto the operation field images observed on the monitors. The position of each organ in the overlaid image closely corresponded with that of the actual organ. Intraoperative information generated from this system provided us with useful navigation. However, several problems such as registration error and lack of depth knowledge were noted.ConclusionThe image display system appeared to be useful in performing hepatobiliary surgery under laparotomy. Further improvement of the system with individualized function for each operation will be essential, with feedback from clinical trials in the future.

Does preoperative pancreatic duct stenting prevent pancreatic fistula after surgery? A cohort study

BACKGROUND/OBJECTIVE Postoperative pancreatic fistula remains a major complication after pancreatic surgeries. To prevent pancreatic fistula, one of the employed management strategies is pancreatic duct stenting. The purpose of this study was to evaluate the efficacy and safety of preoperative pancreatic stenting to prevent pancreatic fistula after surgery. METHODS Subjects comprised 18 consecutive patients who underwent pancreatic surgeries. Patients were divided into 2 groups: stenting group (n=7); and non-stenting group (n=11). Complications after stent placement were analyzed. Compared parameters between groups included background, incidence and grading of pancreatic fistula as judged by international study group of pancreatic fistula (ISGPF) criteria, duration until drain removal, and mean maximum level of drain amylase. RESULTS Two patients displayed mild pancreatitis with high serum amylase levels after stenting. No significant differences in background or any other compared parameters to assess drainage effect were identified between stenting and non-stenting groups. Complications related to placement of the stent tube occurred in 4 patients with tube occlusion or cholestasis. CONCLUSIONS Although drainage effect in the stenting group was compared with that in the non-stenting group, no obvious effect was obtained. This procedure seems to require further investigation on indications for postoperative drainage to decrease the incidence of pancreatic fistula.

Switching from tacrolimus to cyclosporine A to prevent primary biliary cirrhosis recurrence after living-donor liver transplantation.

Recurrence of primary biliary cirrhosis (PBC) after liver transplantation has been shown to negatively affect graft and patient survival. Recently, protective effects of cyclosporine A against PBC recurrence after liver transplantation have been reported. Participants were 4 patients who underwent living-donor liver transplantation (LDLT) for end-stage liver disease due to PBC. Tacrolimus was used for initial immunosuppression, and this was switched to cyclosporine A at least 3 months after liver transplantation. Targeted trough level of cyclosporine A was 20 times that of tacrolimus. We assessed liver and renal function, as well as antimitochondrial M2 antibody for recipients prior to LDLT, as well as before and after switching immunosuppressive agents. Patients were 1 man and 3 women, and they were ages 45 to 47 years at LDLT. Timing of switching from tacrolimus to cyclosporine A was 13, 3, 7, and 4 months respectively after liver transplantation, and all 4 patients have been on cyclosporine A without adverse effects at 20 to 46 months after transplantation. In 2 of 4 patients who had high titers of antimitochondrial M2 antibody before transplantation, antibody titer did not elevate after LDLT. In the other 2 patients without elevation of antimitochondrial M2 antibody, the titer did not turn positive. Switching from tacrolimus to cyclosporine A was possible without medical problems, and all patients exhibit no recurrence of PBC. Cyclosporine A may be useful for prevention of PBC recurrence after LDLT.

Efficacy of nasopancreatic stenting prior to laparoscopic enucleation of pancreatic neuroendocrine tumor.

We report a patient who underwent laparoscopic enucleation for a nonfunctioning pancreatic neuroendocrine tumor. The patient was a 55‐year‐old man who had a 12‐ × 11‐mm tumor close to the main pancreatic duct (MPD) in the pancreatic body. To avoid and detect injury to the main pancreatic duct during operation, a nasopancreatic drainage stent (NPDS) was endoscopically placed prior to the operation. According to the NPDS, the relation between the tumor and MPD was easily identified by laparoscopic ultrasonography during enucleation, thus enabling the resecting line to be determined. Moreover, after enucleation, pancreatography through the NPDS was able to clarify the absence of injury to the MPD. The NPDS was removed postoperatively, and the patient was discharged uneventfully on postoperative day 8. Preoperative placement of the NPDS seems to be a useful option for performing safe laparoscopic enucleation of pancreatic neuroendocrine tumor, especially when the lesion is located close to the MPD.

EUS-guided rendezvous drainage for pancreatic duct obstruction from stenosis of pancreatojejunal anastomosis after pancreatoduodenostomy.

A 79-year-old man underwent pancreatoduodenectomy with Imanaga reconstruction for an ampullary adenocarcinoma in 2003. After that, he experienced recurrent pancreatitis with a suspicious stenotic pancreatojejunal anastomosis. Although endoscopic drainage through the pancreatojejunal anastomosis was attempted, the stenotic anastomosis could not be located endoscopically. Therefore, endosonography-guided rendezvous drainage through the anastomosis was performed, and endoscopic pancreatic stent placement was successfully completed. Thereafter, the patient did not experience any further attacks of pancreatitis. Endosonography-guided rendezvous drainage is a feasible treatment option for recurrent pancreatitis due to stenosis of pancreatojejunal anastomosis.

Usefulness of Pancreatic Duct Stenting prior to Surgery as a Guide to Decide the Feasibility of Limited Pancreatic Resection

Background/Aims: The purpose of this study was to introduce our procedure of limited pancreatic resection with preoperative pancreatic duct stenting to prevent complications. Patients and Methods: Subjects comprised 6 patients with neoplasm who underwent preoperative pancreatic stenting. Pancreatic stents were placed within 7 days before elective surgery. After intraoperative ultrasonography, the relationship between the main pancreatic duct (MPD) and the lesion was confirmed by measuring the distance. Partial resection was surrendered if a sufficient margin of excised tumor was not obtained or injury to the MPD was likely to occur. Branches of pancreatic duct recognized were ligated as much as possible. Results: Mild pancreatitis was present after stenting in 2 patients. Three patients actually underwent partial resection. In patients with partial resection, enhanced visualization of the MPD was useful for deciding the operative procedure and prevented iatrogenic injury to the MPD during dissection. Conclusions: Pancreatic duct stenting prior to pancreatic surgery seems useful as a guide for determining the feasibility of limited pancreatic resection and to prevent missing injury to the MPD.

Single‐incision laparoscopic surgery for giant hepatic cyst

The aim of this study was to assess the feasibility and safety of single‐incision laparoscopic fenestration and to introduce a new surgical technique. Laparoscopic fenestration has become a standard approach for symptomatic hepatic cysts because of the low recurrence rate and minimal postoperative pain. The single‐incision laparoscopic surgery (SILS) technique has increasingly gained acceptance and is now applied to a variety of organs and operations.