Yuichi Hosokawa

Usefulness of multi‐3‐dimensional computed tomograms fused with multiplanar reconstruction images and peroral cholangioscopy findings in hilar cholangiocarcinoma

Multiplanar reconstruction (MPR) images are used for assessing horizontal and vertical extent of hilar cholangiocarcinoma, while peroral cholangioscopy (POCS) is used for diagnosing ductal spread and mapping biopsy. We fused conventional 3‐dimensional computed tomography (3DCT) with MPR images and POCS findings for preoperative assessment of cholangiocarcinoma. The extent of cancer was assessed using MPR images, which were plotted and fused onto 3DCT cholangiography. In addition, the results of mapping biopsy performed under POCS were marked on virtual endoscopic imaging and transferred onto a 3DCT image. Once an angiographic CT image was fused, a multi‐3DCT image was created. The incision line was determined based on these images. Multi‐3DCT images were created for 13 patients with hilar cholangiocarcinoma. Of 10 patients who underwent POCS, superficial spread was observed in two. Resection was performed in 12 patients. In two cases, the cut end of the intrahepatic bile duct was positive, resulting in 83.3% diagnostic accuracy for horizontal spread. In all patients, the estimated number of bile ducts was the same as the number of the actual resections. R0 resection was achieved in 10 patients (83.3%). Multi‐3DCT imaging proved useful in diagnosing longitudinal ductal spread of hilar cholangiocarcinoma.

Serum SPan-1 Is a Significant Risk Factor for Early Recurrence of Pancreatic Cancer after Curative Resection

Background/Aims: Curative resection is still the only treatment for patients with pancreatic ductal adenocarcinoma (PDAC). However, early postoperative recurrence occurs frequently. The aim of this study was to investigate the predictors of early recurrence of PDAC. Methods: Clinical data of 172 consecutive patients with PDAC who underwent curative resection (R0) between 2000 and 2015 at Tokyo Medical University Hospital were retrospectively analyzed. Results: The median follow-up period was 18.2 months. Recurrence occurred in 96 of 172 (55.8%) patients, 27 in whom recurrence occurred within 6 months (early recurrence). Median survival time of the early recurrence group was 10.7 months. The optimal cutoff concentrations for the prediction of early recurrence were 111.3 U/ml, 3.0 ng/ml, 41 U/ml and 670 U/ml for CA19-9, carcinoembryonic antigen, SPan-1 and DUPAN-2, respectively. Multivariate analysis demonstrated that a SPan-1 concentration of >41 U/ml, having received neoadjuvant therapy and having never received adjuvant chemotherapy were significant and independent predictors of early recurrence. Conclusion: A preoperative SPan-1 concentration of >41 U/ml is a significant and independent predictor of the early recurrence of pancreatic adenocarcinoma.

Hemosuccus pancreaticus diagnosed by contrast-enhanced endoscopic ultrasonography (with video)

Hemosuccus pancreaticus, a condition in which blood is expelled into the duodenum via the main pancreatic duct, is a rare cause of acute gastrointestinal bleeding. The common causes of hemosuccus pancreaticus are a pancreatic pseudoaneurysm and pseudocyst due to chronic pancreatitis. We describe a case of hemosuccus pancreaticus caused by a pancreatic pseudoaneurysm due to chronic pancreatitis, which was diagnosed by contrast-enhanced endoscopic ultrasonography (CE-EUS). A 71-year-old man with a long history of alcohol abuse was referred to our hospital with severe anemia and tarry stools. Laboratory data showed a very low hemoglobin level of 4.8 mg/dL. The patient thus received a blood transfusion. Upper GI endoscopy demonstrated no obvious lesion. Computed tomography (CT) revealed a 4.2-cm cystic mass in the pancreatic head with slight contrast-enhancement in the early phase and strong contrast-enhancement in the late phase (Fig. 1). CT also revealed dilatation of the main pancreatic duct and atrophy in the pancreatic body-tail with some small calcifications. Transabdominal ultrasonography showed a 20-mm anechoic area in the pancreatic head and a color Doppler signal was identified in the area. Since a pseudoaneurysm was suspected, angiography was performed. Angiography of the superior mesenteric artery revealed a slight pooling of a contrast medium corresponding to the anechoic area (Fig. 2). However, this was not a typical finding of a pseudoaneurysm. Two days later, since the patient had obstructive jaundice caused by the compression of the enlarged cyst, endoscopic retrograde cholangiopancreatography was performed for biliary decompression. Notably, a duodenoscope showed hemorrhage from the papilla of Vater (Fig. 2). Thus, after biliary stenting, we performed CE-EUS using Sonazoid to identify the origin of the hemorrhage. A fundamental EUS image showed an anechoic lesion similar to that seen on transabdominal ultrasonography (Video S1). Interestingly, 22 seconds after the contrast injection, microbubbles were clearly shown to go into the small feeding artery flowing into the pancreatic head cavity (Fig. 3, Video S1). As previous angiography failed to detect the small feeding artery flowing into the cavity, we speculated that it might be difficult to perform coil embolization on angiography. In addition, the patient had obstructive jaundice due to cyst compression and already received a 16-unit blood cell transfusion. Thus, the patient underwent emergent pylorus-preserving pancreatoduodenectomy as essential therapy. The patient showed good recovery without any adverse events postoperatively. Macroscopic findings showed excessive blood clot in the pancreatic head cavity (Fig. 4). Microscopic specimens showed hemorrhage originating from the ruptured small artery, which flowed into the pancreatic head cavity of which a small portion was covered with an epithelium (Fig. 4). The final diagnosis was hemosuccus pancreaticus derived from a pseudoaneurysm. To the best of our knowledge, this is first report of hemosuccus pancreaticus due to a ruptured artery diagnosed by CE-EUS. CE-EUS may also have other potential applications such as for the close examination of vascular K. Yamamoto · T. Itoi (*) · T. Horibe Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan e-mail: itoi@tokyo-med.ac.jp

Surgical Outcomes of Pancreaticoduodenectomy for Pancreatic Cancer with Proximal Dorsal Jejunal Vein Involvement

Background/PurposeThe proximal jejunal vein which branches from the dorsal side of the superior mesenteric vein (SMV) usually drains the inferior pancreatoduodenal veins (IPDVs) and contacts the uncinate process of the pancreas. We focused on this vein, termed the proximal dorsal jejunal vein (PDJV), and evaluated the anatomical classification of the PDJV and surgical outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) with PDJV involvement (PDJVI).MethodsThe jejunal veins that branch from the dorsal side of the SMV above the inferior border of the duodenum are defined as PDJVs. We investigated 121 patients who underwent upfront pancreaticoduodenectomy for PDAC between 2011 and 2017; PDJVs were resected in all patients. The anatomical classification of PDJV was evaluated using multidetector computed tomography. Surgical and prognostic outcomes of pancreticoduodenectomy for PDAC with PDJVI were evaluated.ResultsThe PDJVs were classified into seven types depending on the position of the first and second jejunal veins relative to the superior mesenteric artery. In all patients, the morbidity and mortality rates were 15.7 and 0.8%, respectively. The rates for parameters including SMV resection, presence of pathological T3–4, R0 resection, and 3-year survival were 46.2, 92.3, 92.3, and 61.1%, respectively, when there was PDJVI (n = 13). When there was no PDJVI (n = 108), the rates were 60.2, 93.5, 86.1, and 58.3%, respectively. Overall, there were no significant differences.ConclusionsPancreaticoduodenectomy with PDJV resection is feasible for PDAC with PDJVI and satisfactory overall survival rates are achievable. It may be necessary to reconsider the resectability of PDAC with PDJVI.

Irreversible Electroporation for Nonthermal Tumor Ablation in Patients with Locally Advanced Pancreatic Cancer: Initial Clinical Experience in Japan

Objective To evaluate irreversible electroporation (IRE) for locally advanced pancreatic cancer (LAPC). Methods This study was approved by our local review board. Eight patients with histologically proven LAPC ≤5 cm were prospectively enrolled to undergo ultrasound-guided IRE. The primary endpoint was complications within 90 days. Secondary outcomes were the overall survival (OS) and time to local progression. Safety was assessed using Common Terminology Criteria for Adverse Events Version 4.0. Results All patients were treated successfully. The median procedure time was 150 min. The median largest tumor diameter was 29.5 mm (20.0-48.0 mm) in the pancreatic head (n=5) and body (n=3). Open (n=4) and percutaneous (n=4) approaches were used. No patients died within 90 days after IRE. There were 5 minor complications in 3 patients and 4 major complications in 3 patients. The incidence rates of major complications did not differ significantly between the approaches. The median time to local progression after IRE was 12.0 months, and the median OS was 17.5 months from IRE and 24.0 months from the diagnosis, with no significant differences between the approaches. Conclusions Percutaneous and open IRE may be acceptable for patients with LAPC (despite some major adverse events) and may represent a useful new therapeutic option.

Surgical resection of neuroendocrine tumors of the pancreas (pNETs) by minimally invasive surgery: the laparoscopic approach

Neuroendocrine tumors of the pancreas (pNETs) are a rare group of neoplasms that originate from the endocrine portion of the pancreas. Tumors that either secrete or do not secrete compounds, resulting in symptoms, can be classified as functioning and non-functioning pNETs, respectively. The prevalence of such tumors has recently increased due to the use of more sensitive imaging techniques, such as multidetector computed tomography, magnetic resonance imaging and endoscopic ultrasound. The biological behavior of pNETs varies widely from indolent, well-differentiated tumors to those that are far more aggressive. The most effective and radical treatment for pNETs is surgical resection. Over the last decade, minimally invasive surgery has been increasingly used in pancreatectomy, with laparoscopic pancreatic surgery (LPS) emerging as an alternative to open pancreatic surgery (OPS) in patients with pNETs. Non-comparative studies have shown that LPS is safe and effective. In well-selected groups of patients with pancreatic lesions, LPS was found to results in good perioperative outcomes, including reduced intraoperative blood loss, postoperative pain, time to recovery, and length of hospital stay. Despite the encouraging results of studies from highly specialized centers with extensive experience, no randomized trials to date have conclusively validated these findings. Indications for minimally invasive LPS for patients with pNETs remain unclear. This review presents the current state of LPS for pNETs.

Liver metastasis is established by metastasis of micro cell aggregates but not single cells

Cancer cell engraftment in the target organ is necessary to establish metastasis. Clinically, lymph node metastasis of single cells has been confirmed using cytokeratin staining. In the current study, a LacZ-labeled cancer cell line was used to visualize intrahepatic metastasis of single cells or liver micrometastasis. KM12SM-lacZ stably expressing LacZ was prepared with a highly metastatic colon cancer cell line, KM12SM. KM12SM-lacZ was injected into the spleen of nude mice and following 1 week the spleen was excised. The liver was then examined for metastasis following 1, 2 or 3 weeks. Confirmation of liver metastasis was completed by observing the grade of metastasis. Grade-1 metastasis (DNA level), human DNA in liver tissue was detected; Grade-2 metastasis (metastasis of single cells), confirmed by X-gal staining; Grade-3 metastasis (histopathological micrometastasis), diagnosed by light microscopy and Grade-4 metastasis (typical metastasis), easily detected macroscopically or by hematoxylin and eosin staining. The Grade-1 metastasis detection rates 1, 2 and 3 weeks following splenectomy were 50, 100 and 100%, respectively. Grade-2 metastasis was not detected by microscopy. The Grade-3 metastasis detection rates for 1, 2 and 3 weeks were 75, 100 and 100%, respectively. Micrometastasis was observed in the portal vein lumen and wall. The Grade-4 metastasis detection rates were 50, 100 and 100% for 1, 2 and 3 weeks respectively. Cancer cells were present in vessels surrounding the main tumor. In conclusion, a specific number of cancer cell aggregates may be necessary to establish hematogenous metastasis.

Laparoscopic distal pancreatectomy without needle aspiration before resection for giant mucinous cell neoplasms.

Laparoscopic resection of large mucinous cystic neoplasms (MCN) has recently been reported. However, in most reports, needle aspiration of the cyst contents was performed before resection and can cause dissemination. Here, we report two patients with giant MCN: a 26‐year‐old woman with a 23‐cm MCN and a 41‐year‐old woman with an 18‐cm MCN. The MCN were successfully resected without aspiration by laparoscopic surgery. CT revealed no tumor involvement of the origins of the splenic artery and vein in either case. In case 1, we performed hand‐assisted laparoscopic surgery while dissecting around the spleen, whereas case 2 underwent pure laparoscopic surgery. No postoperative complications occurred in either case, indicating that laparoscopic distal pancreatectomy for giant MCN is feasible without aspiration in patients without splenic artery and vein origin involvement.