Hepatopancreatoduodenectomy for local recurrence of cholangiocarcinoma after excision of a type IV-A congenital choledochal cyst: a case report.

Surgical resection is the only curative treatment for biliary tract cancer (BTC); however, the recurrence rate remains high even after curative resection. There are limited data regarding the effectiveness of surgical resection for recurrent BTC. We report the favorable survival outcome of a patient who underwent a hepatopancreatoduodenectomy for local recurrence of cholangiocarcinoma after excision of a type IV-A congenital choledochal cyst. The patient, a 25-year-old woman, had undergone excision of a type IV-A congenital choledochal cyst with hepaticojejunostomy. The resected specimen revealed an early cholangiocarcinoma. The local recurrence at the site of anastomosis was detected 4 years and 4 months after surgery. We performed a left trisectionectomy with caudate lobectomy combined with hepatic artery and portal vein resections and a pancreaticoduodenectomy. Histological examination revealed a moderately differentiated adenocarcinoma, and the final diagnosis was recurrence of cholangiocarcinoma. There are a few reports of extensive resection for recurrence of BTC; however, aggressive surgery is possible and may offer favorable survival in selected patients.

Efficacy of perioperative synbiotics treatment for the prevention of surgical site infection after laparoscopic colorectal surgery: a randomized controlled trial.

PURPOSE: The aim of this study was to assess the effect of perioperative oral administration of synbiotics on the surgical outcome in patients undergoing laparoscopic colorectal resection. METHODS: In this single-center randomized, controlled trial, patients scheduled to undergo elective laparoscopic colorectal surgery were eligible to participate and randomly assigned to a synbiotics group or a control group. The primary study outcome was the development of infectious complications, particularly surgical site infection (SSI), within 30 days of surgery. RESULTS: In this study, 379 patients were enrolled and randomly assigned (173 to the synbiotics group and 206 to the control group), of whom 362 patients (168 to the synbiotics group and 194 to the control group) were eligible for this study. SSI occurred in 29 (17.3%) patients in the synbiotics group and 44 (22.7%) patients in the control group (OR: 0.761, 95% CI 0.50-1.16; p = 0.20). Overall, the rate of postoperative complications, including anastomotic leakage, did not differ significantly between the two groups. Synbiotics treatment reversed the changes in fecal bacteria and organic acids after surgery and suppressed the increases in potentially pathogenic species, such as Clostridium difficile. CONCLUSION: The efficacy of perioperative administration of synbiotics was not validated as a treatment for reducing the incidence of infectious complications after laparoscopic colorectal resection. However, the microbial imbalance, in addition to the reduction in organic acids, could be improved by perioperative synbiotics treatment.

Laparoscopic versus open surgery for complicated appendicitis in adults: a randomized controlled trial.

BACKGROUND: The aim of this study was to assess whether laparoscopic appendectomy (LA) for complicated appendicitis (CA) effectively reduces the incidence of postoperative complications and improves various measurements of postoperative recovery in adults compared with open appendectomy (OA). METHODS: This single-center, randomized controlled trial was performed in the Nagoya Daini Red Cross Hospital. Patients diagnosed as having CA with peritonitis or abscess formation were eligible to participate and were randomly assigned to an LA group or an OA group. The primary study outcome was development of infectious complications, especially surgical site infection (SSI), within 30 days of surgery. RESULTS: Between October 2008 and August 2014, 81 patients were enrolled and randomly assigned with a 1:1 allocation ratio (42, LA; 39, OA). All were eligible for study of the primary endpoint. Groups were well balanced in terms of patient characteristics and preoperative levels of C-reactive protein. SSI occurred in 14 LA group patients (33.3 %) and in 10 OA group patients (25.6 %) (OR 1.450, 95 % CI 0.553-3.800; p = 0.476). Overall, the rate of postoperative complications, including incisional or organ/space SSI and stump leakage, did not differ significantly between groups. No significant differences between groups were found in hospital stay, duration of drainage, analgesic use, or parameters for postoperative recovery except days to walking. CONCLUSION: These results suggested that LA for CA is safe and feasible, while the distinguishing benefit of LA was not validated in this clinical trial.

Laparoscopic subtotal cholecystectomy for severe cholecystitis.

BACKGROUND: The concept of laparoscopic subtotal cholecystectomy (LSC), without approaching Calot's triangle to avoid both laparotomy and serious complications, is not widely accepted. In this study, we evaluated the outcomes of LSC for severe cholecystitis when dissection of the cystic duct and cystic artery is hazardous. METHODS: From January 2004 to December 2013, 110 consecutive patients who underwent LSC without ligation of the cystic duct and vessels were enrolled in this retrospective study. Their clinical records, including operative records and outcomes, had been entered into a prospectively maintained database and were analyzed. RESULTS: The mean operating time and blood loss were 121 min and 33.8 ml, respectively. All LSCs were completed without conversion to an open procedure. No injuries to the bile duct or vessels were experienced. Postoperative complications occurred in ten (9.1%) patients, including subhepatic hematoma in 3, bile leakage in 3, and subhepatic abscess in 1. Patients recovered from complications without requiring re-operation. During follow-up periods (mean 30.7 months), symptomatic biliary stone diseases relapsed in three patients (2.7%) and were successfully treated by endoscopic management. CONCLUSIONS: LSC without an attempt to dissect Calot's triangle is a safe and feasible procedure that can avoid conversion to laparotomy.

Hepatopancreatoduodenectomy with arterial reconstruction for extrahepatic cholangiocarcinoma with celiac axis obstruction: report of a case.

We report a case of successful right hepatectomy plus pancreatoduodenectomy (Rt-HPD) with arterial reconstruction for extrahepatic bile duct carcinoma with obstruction of the celiac axis in a 76-year-old man. Obstruction of the celiac axis resulted in arterial blood supply to the upper abdominal organs coming from the pancreatic head arcade. The patient underwent arterial reconstruction before the Rt-HPD to maintain the blood supply from the pancreatic head arcade for as long as possible. His postoperative course was uneventful and he was well with no sign of recurrence when last seen, 64 months after surgery. To our knowledge, this is the first description of this modified HPD with arterial reconstruction. Thus, rational surgical planning based on careful preoperative assessment would expand the indications for HPD, even for patients with celiac axis obstruction requiring arterial reconstruction.

[Complications after implantation of subcutaneous central venous port].

We retrospectively reviewed 500 cases who were implanted with subcutaneous central venous port(CV port)in our institution from Jan. 2007 to Nov. 2011, to investigate the complications arising after CV port implantation. The purpose of CV port implantation was chemotherapy access in 279 cases and home parenteral nutrition in 221 cases. The primary diseases were malignancy in 441 cases(colorectal cancer 252 cases, gastric cancer 54 cases, etc.)and benign diseases in 59 cases. Seven patients(1. 4%)had complications at implantation(pneumothorax 6 cases, catheter migration 1 case). Forty-three patients(8. 6%)had complications after port implantation. Among them, 18 suffered port infection, 10 had obstruction of the catheter system, 4 developed skin ulceration, 4 developed port rotation, 3 had venous thrombosis, and 3 developed catheter migration. The cumulative patency rates after 1, 2, and 3 years were 90. 7%, 81. 2%, and 74. 6%, respectively. Complications after port implantation were more frequently developed in home parenteral nutrition than in chemotherapy.

Clinical and oncologic safety of laparoscopic surgery for obstructive left colorectal cancer following transanal endoscopic tube decompression.

BACKGROUND: Little information has been available concerning the safety of laparoscopic resection of obstructive colorectal cancer after transanal endoscopic tube decompression (TETD). The aim of this study was to assess the short- and long-term outcomes of laparoscopic surgery following TETD for such advanced colorectal cancer. METHODS: A retrospective review was performed of 40 patients with obstructive left colorectal cancer whose distended bowels were treated with TETD before laparoscopic surgery, between January 2001 and March 2011 (TETD group). The elective surgery resulted in potentially curative resection of the tumor in all cases. Their clinical records were compared to those of 80 matched controls with nonobstructive left colorectal cancer resected laparoscopically during the same period (control group). RESULTS: Operative time, blood loss, and the rate of conversion to laparotomy were comparable between the two groups. There were no significant between-group differences in morbidity rates. Five-year overall survival rates in the TETD and control groups were 71.9 and 75.4%, respectively, with no statistical difference. Disease-free survival rates after 5 years were also similar (TETD group, 64.5% vs. control group, 66.3%). There were no significant differences between the two groups in recurrence rates and patterns. CONCLUSION: These results suggest that laparoscopic surgery following TETD is clinically and oncologically safe and could be a treatment of choice for obstructive left colorectal cancer.

Clinical value of additional resection of a margin-positive proximal bile duct in hilar cholangiocarcinoma.

BACKGROUND: Based on frozen section examination, additional resection of the proximal bile duct was performed to achieve a negative margin at the time of resection of hilar cholangiocarcinoma. The aim of this study was to determine whether additional resection of a margin-positive proximal duct can improve survival. METHODS: The records of 303 resected patients with hilar cholangiocarcinoma were reviewed, focusing on the status of the proximal ductal margin. RESULTS: Frozen section examination of the proximal ductal margin was carried out in 138 of the 303 patients included in this study. The histopathologic diagnosis was negative in 110 patients, positive with carcinoma in situ in 11, and positive with invasive cancer in 17. In the 17 patients with invasive cancer, additional resection was performed in 12. The length of resection was 5 mm in the proximal duct is difficult after maximal or near-maximal resection of the duct. Such limited resection of a margin-positive proximal duct does not improve survival, even when a negative margin can be achieved with additional resection.

A rare surgical case of multiple liver resections for recurrent liver metastases from pancreatic gastrinoma: liver and vena cava resection.

Pancreatic gastrinoma is a rare non-beta islet cell tumor. Approximately 60% of gastrinomas are malignant; despite the fact that they are usually slow growing, liver metastases have a major impact on prognosis. Most authors have advocated aggressive surgical management as being the only potentially curative therapy to improve survival as well as to provide outstanding relief from symptoms. We present a case of a 57-year-old man referred to our hospital with a diagnosis of liver metastases from pancreatic gastrinoma, with suspected involvement of the inferior vena cava (IVC). At the age of 37 years, he was diagnosed in his local hospital as having a pancreatic gastrinoma, with liver metastases, and he underwent distal pancreatectomy, splenectomy and enucleation of liver metastases. A liver tumor recurred twice, 7 and 9 years after the first surgery, for which double liver resections were performed: the first time he underwent enucleation of multiple liver metastases in segments II, III, IV, V, VI, VII and VIII, with resection of the right hepatic vein and partially resection of the diaphragm; the second time he underwent enucleation of multiple liver metastases in segments II, III, IV, and V. In our hospital, 8 years after the last surgery, the patient underwent right extended trisectionectomy, resection of segment I, combined resection of the IVC, and partial removal of the diaphragm. To the best of our knowledge, from a review of the literature, this is the first case to achieve successful long-term survival through aggressive surgical management of this type of metastatic endocrine tumor. The patient described here is still alive, free of disease and leading a normal life, 20 years after the initial diagnosis and 3 years after the last surgery.