Yoshimi Iwasaki

Intraoperative exploration of biliary anatomy using fluorescence imaging of indocyanine green in experimental and clinical cholecystectomies

Background/purposeWe evaluated the usefulness of intraoperative exploration of the biliary anatomy using fluorescence imaging with indocyanine green (ICG) in experimental and clinical cholecystectomies.MethodsThe experimental study was done using two 40-kg pigs and the clinical study was done in 12 patients for whom cholecystectomy was planned from January 2009 to June 2009. Initially we used a laparoscopic approach for the evaluation of fluorescence imaging of the biliary system in the two pigs. Then the clinical study was started on the basis of these experimental results. ICG (1.0xa0ml/body of 2.5xa0mg/ml ICG) was infused 1–2xa0h before surgery. With the subjects under general anesthesia we observed in real time the condition of the biliary tract under the guidance of fluorescence imaging employing an infrared camera or a prototype laparoscope. ICG was added intravenously to observe the location or flow condition of the cystic artery.ResultsWe obtained a clear view of the biliary tract and the location of the cystic duct in the two pigs. Local compression with a transparent hemispherical plastic device was effective for offering a clearer view. The biliary tract, except for the gallbladder, was clearly recognized in all clinical subjects. Local compression with a transparent hemispherical plastic device for open cholecystectomy and a flat plastic device for laparoscopy provided clearer visualization of the confluence between the cystic duct and common bile duct or common hepatic duct. The location of the cystic artery was revealed after division of the connective tissues, and the flow condition of the cystic artery was confirmed 7–10xa0s after intravenous re-infusion of ICG. There were no adverse events related to the intraoperative procedure or the ICG itself.ConclusionsThis method is safe and easy for the identification of the biliary anatomy, without requiring cannulation into the cystic duct, X-ray equipment, or the use of radioactive materials. Although fluorescence imaging is still at an early stage of application in comparison with ordinary intraoperative cholangiography, we expect that this method will become routine, offering a lower degree of invasiveness that will help avoid bile duct injury.

A Novel Approach for Sentinel Lymph Node Identification Using Fluorescence Imaging and Image Overlay Navigation Surgery in Patients with Breast Cancer

BackgroundWe reported a novel technique of sentinel lymph node (SLN) identification using fluorescence imaging of indocyanine green injection. Furthermore, to obtain safe and accurate identification of SLN during surgery, we introduce the image overlay navigation surgery and evaluate its efficacy.MethodsThis study enrolled 50 patients with a tumors <2xa0cm in diameter. Initially, we obtained three-dimensional (3-D) imaging from multidetector-row computed tomography (MD-CT) by volume rendering. It was projected on the patient’s operative field with the clear visualization of lymph node (LN) through projector. Then, the dye of indocyanine green (ICG) was injected subdermally in the areola. Subcutaneous lymphatic channels draining from the areola to the axilla were visible by fluorescence imaging immediately. Lymphatic flow was reached after LN revealed on 3-D imaging. After incising the axillary skin on the point of LN mapping, SLN was then dissected under the guidance of fluorescence imaging with adequate adjustment of sensitivity and 3-D imaging.ResultsLymphatic channels and SLN were successfully identified by Photodynamic eye (PDE) in all patients. And the sites of skin incision also were identical with the LN being demonstrated by 3-D imaging in all patients. The mean number of SLN was 3.7. The image overlay navigation surgery was visually easy to identify the location of SLN from the axillary skin. There were no intra- or postoperative complications associated with SLN identification.ConclusionsThis combined navigations of fluorescence and 3-D imaging revealed more easy and effective to detect SLN intraoperatively than fluorescence imaging alone.

Preoperative thrombocytosis is associated with survival after surgery for colorectal cancer

To evaluate the influence of preoperative thrombocytosis on survival after surgery in patients with colorectal cancer (CRC).

Clinical Significance of the C-Reactive Protein to Albumin Ratio for Survival After Surgery for Colorectal Cancer

ObjectiveThis study was designed to estimate the clinical significance of the C-reactive protein (CRP)/albumin ratio (CAR) for prediction of postoperative survival in patients with colorectal cancer (CRC).BackgroundThe Glasgow Prognostic Score (GPS), calculated from the serum levels of CRP and albumin, is well known to be a valuable inflammation-based prognostic system for several types of cancer. A recent study has demonstrated that the CAR is also useful for prediction of treatment outcome in patients with hepatocellular carcinoma.MethodsUni- and multivariate analyses using the Cox proportional hazards model were performed to detect the clinical characteristics that were most closely associated with overall survival (OS). All recommended cutoff values were defined using receiver operating characteristic curve analyses. Kaplan–Meier analysis was used to compare OS curves between the two groups.ResultsA total of 627 patients who had undergone elective CRC surgery were enrolled. Multivariate analysis using the results of univariate analyses demonstrated that CAR (>0.038/≤0.038) was associated with OS (hazard ratio 2.596; 95xa0% confidence interval 1.603–4.204; Pxa0<xa00.001) along with pathological differentiation (others/well or moderately), carcinoembryonic antigen level (>8.7/≤8.7, ng/ml), stage (III, IV/0, I, II), neutrophil to lymphocyte ratio (NLR) (>2.9/≤2.9), and GPS (2/0, 1). Kaplan–Meier analysis and log rank test demonstrated a significant difference in OS curves between patients with low CAR (≤0.038) and those with high CAR (>0.038; Pxa0<xa00.001).ConclusionsCAR is as useful for predicting the postoperative survival of patients with CRC as previously reported inflammation-based prognostic systems, such as GPS and NLR.

Inflammation-based prognostic system predicts postoperative survival of colorectal cancer patients with a normal preoperative serum level of carcinoembryonic antigen.

BackgroundAlthough carcinoembryonic antigen (CEA) is a valuable indicator for estimating the progression of colorectal cancer (CRC), some patients with advanced CRC show no elevation of the CEA level. On the other hand, inflammation-based prognosis, assessed by the Glasgow Prognostic Score (GPS), has been established as one of the important prognostic factors of survival after surgery for several types of cancer. We estimated the postoperative survival of CRC patients with a normal preoperative serum level of CEA on the basis of the GPS.MethodsAmong 491 patients who had undergone elective CRC surgery, 271 with a normal preoperative serum CEA level (≤5.0xa0ng/ml) were enrolled. Uni- and multivariate analyses were performed to evaluate the relationship to overall survival. Kaplan–Meier analysis and log rank test were used to compare the survival curves between patients with GPS 0 (group A), and 1 or 2 (group B).ResultsUnivariate analyses using clinical characteristics revealed that lymphatic invasion, lymph node metastasis, platelet count, the serum levels of CEA and C-reactive protein, tumor, node, metastasis staging system (stage 0, I, II/III, IV), and the GPS (0/1, 2) were associated with overall survival. Among these characteristics, multivariate analysis demonstrated that the GPS and platelet count were associated with overall survival. Kaplan–Meier analysis and log rank test demonstrated a significant difference in overall survival between groups A and B (Pxa0<xa00.001).ConclusionsEven if CRC patients have a normal preoperative serum level of CEA before surgery, the GPS is able to predict their postoperative survival.

Inflammation-based prognostic system predicts survival after surgery for stage IV colorectal cancer.

BACKGROUNDnThe aim of this study was to estimate whether the Glasgow prognostic score (GPS) is useful for predicting the survival of patients after surgery for stage IV colorectal cancer (CRC).nnnMETHODSnThe GPS was calculated on the basis of admission data as follows: patients with both an increased C-reactive protein (CRP) level (>1.0 mg/dL) and hypoalbuminemia (<3.5 g/dL) were allocated a score of 2, and patients showing one or none of these abnormalities were allocated a score of 1 or 0, respectively.nnnRESULTSnA total of 108 patients with stage IV CRC were enrolled. Although multivariate analyses showed that tumor pathology, subclass of stage IV CRC, and the GPS were associated with overall survival, the GPS could divide the patients into 3 independent groups showing significant differences in postoperative survival (P = .018).nnnCONCLUSIONSnThe GPS is not only one of the most significant clinical characteristics associated with the overall survival of patients with stage IV CRC, but also a useful indicator that is capable of dividing such patients into 3 independent groups before surgery.

Protective effect of Sivelestat in a porcine hepatectomy model prepared using an intermittent Pringle method

The effect of Sivelestat, a neutrophil elastase inhibitor, on hepatic ischemia-reperfusion injury was examined in a pig hepatectomy model. An internal jugular vein-splenic vein bypass was prepared in male pigs and about 40% hepatic resection (left lobe) was performed under 15-min liver ischemia and 5-min intermittent reperfusion. Six animals received Sivelestat (10 mg/kg/h) intravenously and six control animals received physiological saline (10 mg/kg/h) from commencement of laparotomy. Hemodynamics, blood chemistry, aspartate aminotransferase (AST), lactate dehydrogenase (LDH), lactic acid, hyaluronic acid, nitrite/nitrate (NOS), and tumor necrosis factor-alpha (TNF-alpha) were compared between the groups. The effects of Sivelestat on NOS generation and expression of iNOS mRNA and TNF-alpha mRNA were also assessed in J774 cells. Expression of TNF-alpha mRNA in hepatic tissues was examined using RT-PCR. The blood pressure of control animals was significantly lower immediately and 3 h after ischemia-reperfusion, compared with that at commencement of laparotomy, whereas there was no decrease of blood pressure in animals administered Sivelestat. Serum AST (P=0.0045), NOS (P=0.0098), and TNF-alpha (P=0.041) levels were significantly lower 3 h after hepatectomy in animals receiving Sivelestat. Sivelestat inhibited NOS production in J774 cells, but did not inhibit expression of iNOS mRNA or TNF-alpha mRNA. In hepatic tissues, Sivelestat showed a greater tendency to inhibit expression of TNF-alpha mRNA and fewer TUNEL-positive cells were present in the hepatic sinusoidal endothelium after Sivelestat treatment, although these differences were not statistically significant. We conclude that Sivelestat inhibits production of TNF-alpha and NO by inhibiting neutrophil elastase, and thus reduces hepatic injury and stabilizes hemodynamics after ischemia-reperfusion.

Usefulness of an Inflammation-Based Prognostic Score (mGPS) for Predicting Survival in Patients with Unresectable Malignant Biliary Obstruction

BackgroundAn inflammation-based prognostic score, the modified Glasgow Prognostic Score (mGPS), has been established as a useful tool for predicting postoperative outcome in patients with cancer. However, no studies have investigated the usefulness of the mGPS for prognostication in patients undergoing palliative surgery for unresectable malignant biliary obstruction (UMBO). The present study was conducted to investigate whether the mGPS is useful for predicting the postoperative survival of patients undergoing intraoperative placement of an expandable metal stent for UMBO, or not.MethodsThe mGPS was calculated as follows: patients with both an elevated level of C-reactive protein (CRP) (>1.0xa0mg/dL) and hypoalbuminemia (<3.5xa0g/dL) were allocated a score of 2. Patients with only an elevated CRP level were allocated a score of 1, and patients without an elevated CRP level (≤1.0xa0mg/dL) were allocated a score of 0. Postoperative survival was evaluated by Kaplan–Meier analysis and log rank test. The significance of risk factors for postoperative survival was evaluated with the Cox proportional hazards model.ResultsKaplan–Meier analysis revealed that patients with mGPS 0 (nxa0=xa036) and 1 (nxa0=xa07) had better postoperative survival (pxa0=xa00.017) than patients with mGPS 2 (nxa0=xa017). The 6-month and 1-year survival rates of patients with mGPS 0 and 1 were 58.1 and 27.3xa0%, and those for patients with mGPS 2 were 25.0 and 6.2xa0%, respectively. Multivariate analysis revealed that mGPS (0, 1/2) was a significant risk factor for postoperative survival (hazard ratio 3.271; 95xa0% CI 1.109–9.649; pxa0=xa00.032).ConclusionThe mGPS is not only one of the most significant predictors of postoperative survival for UMBO patients receiving intraoperative biliary stenting but also a useful indicator capable of dividing such patients into two independent groups before surgery.

Patient with adult‐onset type II citrullinemia beginning 2 years after operation for duodenal malignant somatostatinoma: Indication for liver transplantation

We report a 51‐year‐old female patient with adult‐onset type II citrullinemia (CTLN2) who had a history of pancreatoduodenectomy for duodenal somatostatinoma with metastases to regional lymph nodes at age 49 years, paying special attention to indications for liver transplantation. At age 50 years, she developed hepatic encephalopathy with elevation of plasma ammonia and citrulline levels. A diagnosis of CTLN2 was made by DNA analysis of the SLC25A13 gene and treatment with conservative therapies was begun, including a low‐carbohydrate diet and supplementation with arginine and sodium pyruvate. However, despite these treatments, frequent attacks of encephalopathy occurred with markedly elevated plasma ammonia levels. While we were apprehensive regarding the risk of recurrence of somatostatinoma due to immunosuppressive therapy after liver transplantation, the patient was in a critical condition with CTLN2 and it was decided to perform living‐donor liver transplantation using a graft obtained from her son. Her postoperative clinical course was uneventful and she has had an active life without recurrence of somatostatinoma for 2 years. This is the first case of CTLN2 with somatostatinoma. As the condition of CTLN2 patients with rapidly progressive courses is often intractable by conservative therapies alone, liver transplantation should be considered even after surgery for malignant tumors in cases with neither metastasis nor recurrence.

Formation of gastrocolic fistula during treatment for peptic ulcer.

We report a case of gastrocolic fistula (GCF) caused by a gastric ulcer and rare endoscopic findings indicating the early stages of GCF formation. The patient was a 58‐year‐old man who was hospitalized with upper abdominal pain. He was diagnosed as having a gastric ulcer, and was prescribed a proton pump inhibitor (PPI), but did not comply with the medication. One year later, he was again referred with recurrent abdominal pain. Endoscopic examination showed what appeared to be a portion of exposed colonic wall located in the center of an active gastric ulcer, and repeated endoscopy after PPI treatment for 8u2003days demonstrated a typical GCF. A preoperative diagnosis of GCF was made, and the patient underwent wide gastrectomy with partial resection of the transverse colon.