Prognostic factors in gastrointestinal perforation.

BACKGROUND/AIMS: Postoperative complications associated with gastrointestinal (GI) perforation may lead to a poor prognosis. The goal of the study was to identify factors required for the establishment of appropriate perioperative procedures in such cases. METHODOLOGY: The subjects were 51 patients with GI perforation treated from July 2007 to June 2008 in six hospitals in the Minamikawachi district. RESULTS: The perforation sites were the large intestine in 22 cases, small intestine in 15, stomach in 7 and duodenum in 7. Postoperative complications developed in 25 cases (49%), including infection in 20 and respiratory dysfunction in 13. Hospital mortality was 25% and the major causes of death were infection and respiratory dysfunction. The mortality was 52% and 0% in patients with and without postoperative complications, respectively. The mortality was 69% in the 13 patients with postoperative respiratory dysfunction compared to 11% for patients without respiratory dysfunction. Of the 7 patients with large intestine perforation, 4 were treated with sivelestat sodium. These 4 patients had a high mean SOFA score (11.5±1.3), but 2 out of 4 survived. CONCLUSIONS: Postoperative complications occurred in approximately half of the patients with GI perforation and were associated with a poor prognosis. Prevention of respiratory dysfunction is particularly important for an improvement of outcome.

Clinical study for pancreatic fistula after distal pancreatectomy with mesh reinforcement.

BACKGROUND: The purpose of this cohort study was to determine whether distal pancreatectomy with mesh reinforcement can reduce postoperative pancreatic fistula (POPF) rates compared with bare stapler. METHODS: In total, 51 patients underwent stapled distal pancreatectomy. Out of these, 22 patients (no mesh group) underwent distal pancreatectomy with bare stapler and 29 patients (mesh group) underwent distal pancreatectomy with mesh reinforced stapler. The risk factor for clinically relevant POPF (grades B and C) after distal pancreatectomy was also evaluated. RESULTS: Clinical characteristics were almost similar in both the groups. The days of the mean hospital stay and drainage tube insertion in the mesh group were significantly fewer than those in the no mesh group. The mean level of amylase in the discharge fluid in the mesh group was also significantly lower than that the in no mesh group. The rate of clinically relevant POPF (grades B and C ) in the mesh group was significantly lower than that in the no mesh group (p=0.016). Univariate analyses of risk factors for POPF (grades B and C) revealed that only mesh reinforcement was associated with POPF (grades B and C). Moreover, on multivariate analyses of POPF risk factors with p value<0.2 in univariate analyses by logistic regression, mesh reinforcement was regarded as a significant factor for POPF(grades B and C). CONCLUSIONS: The distal pancreatectomy with mesh reinforced stapler was thought to be favorable for the prevention of clinically relevant POPF (grades B and C).

The comparison of clinical results between hand suturing and mechanical stapling for gastrojejunostomy and jejunojejunostomy after SSPPD.

BACKGROUND: Mechanical stapling method is widely established alternative to conventional hand suturing. METHOD: For gastrointestinal anastomoses. In this study, we compare the clinical results of mechanical stapling with those of hand suturing for gastrojejunostomy and jejunojejunostomy after Subtotal Stomach Preserving Pancreaticojejunostomy (SSPPD). METHODS: Between 2002 and 2007, 42 patients who underwent SSPPD with concise records on operative procedure and time required for gastrojejunostomy and jejunojejunostomy were enrolled. Out of 42 patients, the mechanical stapling for gastrojejunostomy and jejunojejunostomy after SSPPD was performed for 19 patients and hand suturing for those in SSPPD was done for 23 patients. RESULTS: All clinical characteristics were similar in both groups. There was no statistical difference between both groups in the rate of complications related to gastrojejunostomy and jejunojejunostomy. However, days of nasogastric intubation and days until liquid diet in the stapled group were significantly shorter than those in the hand sutured group. Time required for gastrojejunostomy and jejunojejunostomy was significantly shorter in the stapled group than in the hand sutured group. CONCLUSIONS: This study suggested that stapled anastomoses might require a shorter time to perform and decreased time for nasogastric intubation and until liquid diet is introduced.

Thoracolithiasis: 11 cases with a calcified intrapleural loose body.

PURPOSE: To describe clinical and imaging characteristics of thoracolithiasis. MATERIALS AND METHODS: Medical records from our center from September 2005 to March 2007 were reviewed. A definitive diagnosis was made by multidetector-row computed tomography studies of the chest, which revealed in each patient an intrapleural calcified nodular opacity, which changed in intrapleural location on serial examinations. Eleven patients fulfilled this criteria. The images were analyzed by experienced radiologists, who focused on the distribution, size, and shape of the thoracolithiasis. RESULTS: The incidence of thoracolithiasis was 0.086% (11 of 12,835 individuals). All the patients were asymptomatic and did not have any history of intrathoracic disease. The nodules ranged in size from 5 to 15 mm (median 8 mm), and were ovoid and smoothly marginated. Each nodule contained homogeneous diffuse calcification. Eight nodules occurred in the left pleural space and 3 in the right. Their locations varied, which included on the diaphragm, along the posterior chest wall of the lower lung, abutting the left cardiac margin, and near the paraspinal space of the lower thoracic spine. Each of the calcified pleural bodies changed in intrapleural location on follow-up computed tomography examination. CONCLUSIONS: The calcified intrapleural nodular opacities of thoracolithiasis tended to be located inferiorly, presumably secondary to the effects of gravity, and they seemed to migrate freely within the pleural cavity.

The clinical results of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy in consecutive 55 cases.

OBJECTIVES: Pancreatic anastomotic leakage remains a major troublesome complication after pancreaticoduodenectomy. Thus, various technical modifications regarding the pancreatic anastomosis after pancreaticoduodenectomy have been attempted to minimize anastomotic leakage. We have performed duct-to-mucosa pancreaticojejunostomy with resection of jejunal serosa (layer-to-layer pancreaticojejunostomy) and obtained extremely favorable results. METHODS: During 1999 to 2006, 55 patients (27 women and 28 men) underwent duct-to-mucosa pancreaticojejunostomy with resection of jejunal serosa after pancreaticoduodenectomy. The mean age was 64.6 years (range, 33-84 years). RESULTS: Median postoperative hospital stay was 32.8 days. Morbidity rate due to early postoperative complication was 9.1% (pneumothorax in 1, pulmonary embolism in 1, gastric ulcer in 1, and wound infection in 2), with no pancreatic anastomotic leakage. CONCLUSIONS: There was low complication rate and no pancreatic anastomotic leakage in consecutive 55 patients who underwent pancreaticoduodenectomy. We consider that duct-to-mucosa pancreaticojejunostomy with resection of jejunal serosa is extremely safe, reliable, and favorable for the anastomosis after pancreaticoduodenectomy.

The surgical procedure and clinical results of subtotal stomach preserving pancreaticoduodenectomy (SSPPD) in comparison with pylorus preserving pancreaticoduodenectomy (PPPD).

BACKGROUND: Subtotal stomach preserving pancreaticoduodenectomy (SSPPD) is compared retrospectively with pylorus preserving pancreaticoduodenectomy (PPPD). METHODS: During 2002-2005, 21 patients (13 female, 8 male) underwent SSPPD. The mean age was 64.3 (range 33-80). PPPD was performed for 12 patients after 1999. Days of hospital stay, operation time, operative blood loss, postoperative morbidity and mortality, days of nasogastric intubation, days until liquid diet, delayed gastric emptying, postoperative change of serum Albumin value, were compared between SSPPD and PPPD. Clinical characteristics (age, gender, benign, or malignant condition, presence of preoperative jaundice, preoperative value of serum Albumin) were analyzed in both procedures. RESULTS: In comparison of clinical characteristics, all factors were similar between PPPD and SSPPD. There were also quite similar results in days of hospital stay, operation time, operative blood loss, postoperative morbidity and mortality. Days of nasogastric intubation, days until liquid diet in PPPD were significantly longer than those in SSPPD and the incidence of delayed gastric emptying in PPPD was significantly higher than that in SSPPD. Finally, PPPD and SSPPD postoperative change of serum Albumin value were statistically similar. CONCLUSIONS: We consider SSPPD as one of the most favorable procedures in patients who undergo pancreaticoduodenectomy.

Clinical results on intra-arterial adjuvant chemotherapy for prevention of liver metastasis following curative resection of pancreatic cancer.

BACKGROUND: We report here the clinical results of intra-arterial adjuvant chemotherapy for the prevention of liver metastasis following curative resection of pancreatic carcinoma. METHODS: Twenty-two patients with pancreatic cancer underwent the radical operation between January 1999 and April 2005. Intra-arterial adjuvant chemotherapy with cisplatin (CDDP) and 5-fluorouracil (5FU) was selectively performed on nine patients; the remaining 13 patients did not receive chemotherapy and comprised the control group. RESULTS: Demographics and clinical characteristics were almost identical in the two groups. Liver metastasis occurred in three of nine patients (33%) in the chemotherapy group and in seven of 13 patients (54%) in the control group. The intra-arterial adjuvant chemotherapy had the tendency to suppress the rate of liver metastasis. The median survival period was 15.8 months for the nine patients who underwent the intra-arterial adjuvant chemotherapy following surgery and 13.4 months for the 13 patients of the control group who were curatively resected without the intra-arterial adjuvant chemotherapy. Cumulative survival rate was improved by the intra-arterial adjuvant chemotherapy. CONCLUSIONS: In patients with pancreatic cancer who underwent the curative operation, the intra-arterial adjuvant chemotherapy had the tendency to suppress the rate of liver metastasis and improve cumulative survival.

New method for prevention of bile leakage after hepatic resection.

BACKGROUND: The usefulness of fibrin glue and bioabsorbable polyglicolic acid (PGA) felt to prevent the bile leakage was studied. METHODS: Eighty-eight patients who underwent hepatic resection without biliary reconstruction from 2001 through 2005 were studied. We divided 88 patients into 37 patients of Group A (who underwent hepatic resection between January 2001 and March 2003) and 51 patients of Group B (who underwent hepatic resection between April 2003 and January 2005). The fibrin glue was applied to the excision site of remnant liver in the patients of Group A. On the other hand, the fibrin glue and bioabsorbable PGA sheet were applied in the patients of Group B. RESULTS: In Group A, the post-operative bile leakage occurred in 3 of 37 patients (8.1%). The post-operative bleeding occurred in 1 of 37 patients (2.7%). And the post-operative wound infection occurred in 4 patients (10.8%). In Group B, no post-operative bile leakage and bleeding were observed in 51 patients. And the post-operative wound infection occurred in 3 patients (5.9%). The difference between Groups A and B in the rate of bile leakage was statistically significant. CONCLUSIONS: The combination of fibrin glue and bioabsorbable PGA felt was extremely favorable for prevention of bile leakage after hepatic resection.

The surgical procedure and clinical results of the duct to mucosa pancreaticojejunostomies with resection of jejunal serosa.

BACKGROUND: Pancreatic anastomotic leakage often results in severe complications of sepsis, intra-abdominal bleeding, pancreatic fistula, and is a significant cause of morbidity and mortality. An appropriate technique to minimize pancreatic leakage is very important. Recently we have performed duct to mucosa pancreaticojejunostomy with resection of jejunal serosa and obtained positive results. PATIENTS AND METHODS: During 1999-2005, 52 patients (25 females, 27 males) underwent duct to mucosa pancreaticojejunostomy with resection of jejunal serosa after pancreatic head resections for benign (n=6) and malignant disease (n=46). The mean age was 64.0 years (range 33-80). RESULTS: Mean post-operative hospital stay was 32.3 days. Morbidity rate due to early post-operative complication was 7.7% (pulmonary embolism in 1, pneumothorax in 1, wound infection in 2), with no pancreatic leakage. CONCLUSIONS: There were low complication rates and an absence of pancreatic anastomotic leakage was observed in 52 patients. We consider that this pancreatic anastomotic technique is extremely favorable for pancreaticojejunostomy.

A resected case of advanced duodenal carcinoma with occlusion of the celiac artery.

A 75-year-old woman with vomiting, admitted on March 7 2002, was diagnosed with advanced duodenal carcinoma based on ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangio-ancreatography (MRCP), percutaneus transhepatic cholangiography. Angiography showed the celiac artery to be occluded. The common hepatic artery was demonstrated via the gastroduodenal artery (GDA). We conducted a probe laparotomy and resected connective tissue with the celiac ganglion and lymph nodes surrounding the celiac artery. The frozen specimen showed no malignancy. Then the celiac artery was exposed and celiac axis compression syndrome was not seen. A portion of the greater saphenous vein was taken from the patient's right thigh and grafted between the common hepatic artery and the supraceliac portion of the aorta. One end of the saphenous vein was anastomosed to the side of the common hepatic artery. The other end of the saphenous vein was anstomosed to the aorta in an end to side fashion. After the reconstruction of celiac circulation, we performed radical pancreaticoduodenectomy. The postoperative course was not eventful and the patient was discharged from the hospital 5 weeks after surgery.

A resected case of multiple intraductal papillary mucinous tumors of the pancreas with US-guided ductal branch-oriented partial pancreatectomy.

A 69-year-old man with epigastralgia was admitted on August 26, 2002 and diagnosed with multiple intraductal papillary mucinous tumors by various imagings. The cystic tumor of pancreas head had a diameter of 2 cm, and the mural nodule of the cystic tumor measured only 3 mm. In the pancreas body the cystic tumor was measured at 1.5 cm with the mural nodule of the cystic tumor measuring 3 mm. It was believed that the tumors were benign. However, a mural nodule of the cystic lesion was recognized, thus, the possibility of malignancy could not be completely ruled out. The reduction operation for preservation of pancreatic parenchyma should be selected for these circumstances. Ductal branch-oriented partial pancreatectomy was performed on September 6, 2002 with intraoperative ultrasonography and a Cavitron Ultrasonic Aspirator, preserving the main pancreatic duct and normal pancreatic parenchyma. The operation was successful, and the histopathological diagnosis of the tumors was intraductal papillary adenoma of the pancreas.