Long-term surgical outcomes of patients with type 1 autoimmune pancreatitis.

BACKGROUND: Although pancreatectomy has sometimes been performed for patients with autoimmune pancreatitis (AIP) presenting atypical radiologic findings under the diagnosis of pancreatobiliary malignancy, the long-term surgical outcome of these patients had not yet been fully elucidated. METHODS: The long-term surgical outcomes of 13 patients with pathologically diagnosed type 1 AIP with immunohistochemical staining for immunoglobulin G4 (IgG4) were retrospectively compared with those of 34 patients with conventional chronic pancreatitis to evaluate the residual pancreatic function. RESULTS: A definite relapse of AIP in terms of the clinical manifestations and diagnostic imaging was not found in any of the patients, although one patient experienced an attack of acute pancreatitis caused by pancreatic stones, and stricture of the hepaticojejunostomy occurred in one patient. The overall body weight decreased significantly more in patients with AIP than in patients with conventional chronic pancreatitis (p < 0.05); however, there was no difference in the preoperative nondiabetic patients. Refractory diarrhea occurred in only one patient with AIP. The cumulative new-onset rates of diabetes mellitus of the ten patients with AIP and 24 patients with conventional chronic pancreatitis at 5 years after the surgery were 32.5 and 26.1 %, respectively (p = 0.70). CONCLUSIONS: Careful long-term follow-up is needed for patients undergoing pancreatectomy for type 1 AIP because remnant pancreatic function can deteriorate as severely as that of patients who undergo pancreatectomy for conventional chronic pancreatitis. In the present series, however, there were few definite manifestations indicating relapse or the persistent existence of AIP.

Is pancreatectomy with arterial reconstruction a safe and useful procedure for locally advanced pancreatic cancer?

BACKGROUND/PURPOSE: We often encounter unresectable pancreatic cancer due to invasions of the major vessels. Vascular resection for locally advanced pancreatic cancers has an advantage in en block local resection. There are potential cases in which good outcomes can be achieved by arterial resection. METHODS: Pancreatectomy (including total pancreatectomy in 15 cases, pancreatoduodenectomy in 7 cases and distal pancreatectomy in one case) was performed in 23 cases of invasive ductal carcinoma of the pancreas, in combination with resection and reconstruction of the hepatic artery in 15 cases, the superior mesenteric artery in 12 cases (there are overlaps) and the portal vein in 20 cases. RESULTS: The median operating time was 686 min (416-1,190 min) and the median blood loss was 2,830 ml (440-19,800 ml). This shows that the surgery was highly-invasive. The operative mortality rate was 4.3%. On the basis of the UICC classification, there were 2 cases of Stage IIa, 4 cases of Stage IIb, 9 cases of Stage III, 8 cases of Stage IV, while there were 18 cases (78.3%) of R0 resection. On the other hand, the final histological findings showed that there were 8 cases (34.8%) of M1 (liver and non-regional lymph node metastases), so it is thought that decisions on operative indications should be not be made slightly. As for the overall survival rate, the 1-year survival rate was 51.2% and the 3-year survival rate was 23.1% while the median survival time (MST) was 12 months. As for 15 cases of M0, the 1-year survival rate was 61.9% and the 4-year survival rate was 38.7% while the MST was 16 months. On the other hand, the MST was poor (10 months) in 8 cases of M1, showing that a statistically significant difference was observed depending upon the degree of metastasis (log-rank P = 0.0409). In 18 cases of R0, the 1-year survival rate was 67.2%, the 4-year survival rate 30.2% and the MST 13 months, respectively, while in 5 cases of R1 and R2, the MST was 6 months, showing that there was a statistically significant difference between R0 cases and R1, R2 cases (log-rank P = 0.0002). CONCLUSIONS: Further discussion is required concerning surgical indications and significance. However, it is thought that resection is useful only when surgery of R0 has taken place for selected locally advanced pancreatic cancer (M0).

In situ surgical procedures for locally advanced pancreatic cancer: partial abdominal evisceration and intestinal autotransplantation.

BACKGROUND/PURPOSE: Pancreatic cancers in which invasion to the root of the mesentery are suspected have been regarded as unresectable in general. We report the surgical techniques in two cases of locally advanced pancreatic cancer for which in situ surgical procedures including partial abdominal evisceration and intestinal autotransplantation were performed. METHODS: The patients were a woman 57 years of age and a man 64 years of age. Both cases had a locally advanced cancer that had originated in the pancreatic uncus and was found to have invaded the root of the mesentery, as well as the superior mesenteric artery (SMA) and the superior mesenteric vein (SMV). The cancers in both patients were assessed as resectable because the jejunal artery and vein were secured intact at a site peripheral from the root of the mesentery, and the origin of the SMA along with the portal and splenic veins was intact at a proximal site, so pancreatectomy and resection of the transverse and ascending colons were performed. The SMA and the SMV were ablated just below each origin at a site proximal to the root of the mesentery. At a distal site, two jejunal arteries and one jejunal vein were kept intact and all the remaining arteries and veins were ablated. The remaining small intestine had become a free autograft. As for the portal and jejunal veins, end-to-end anastomosis was performed. Reconstruction of the SMA was achieved with an end-to-end anastomosis, using the right internal iliac artery as a graft. Reconstruction of the alimentary tract was achieved using small intestine as an autograft. RESULTS: Both patients survived the major operative procedures. Warm ischemia time was 84 min for the SMA and 12 min for the SMV-portal system in Case 1 while it was 30 min for the SMA and 25 min for the SMV-portal system in Case 2. No ex-vivo resection technique was used. Leakage occurred in both cases at the anastomotic lesion between the small intestine and the left colon. Abdominal drainage and conservative treatment were applied in both cases. Cure was achieved within 3 months postoperatively in Case 1 and within 2.5 months in Case 2. Subsequently, the patients returned to their preoperative lives. Case 1 died 11 months and Case 2 died 12 months after the operation due to abdominal dissemination and liver metastases. CONCLUSIONS: We were able to perform in situ procedures including partial abdominal evisceration and intestinal autotransplantation for two cases of pancreatic cancer with possible invasion to the root of the mesentery. There are few reports of such procedures. There has been one report of a case which applied an ex vivo technique. It is expected that the development of adequate adjuvant therapy will lead to further improvement in the prognosis of pancreatic cancers.

Pancreatectomy with reconstruction of the right and left hepatic arteries for locally advanced pancreatic cancer.

BACKGROUND/PURPOSE: The resectability of locally advanced pancreatic cancer depends upon, before anything else, the relationship between the tumor and the adjacent arterial structure. Pancreatic cancer that has developed at the caudal side of the pancreas can invade the common hepatic artery (CHA). Pancreatic cancers with CHA involvement can become candidates for surgery in selected cases. Pancreatic cancer arising at the caudal side of the pancreas head may sometimes invade the right and left hepatic arteries (RLHA) as well as the CHA. Pancreatic cancer with RLHA involvement may be assessed as unresectable unless complex vascular reconstruction is performed. METHODS: We have experienced 3 cases of successfully resected pancreatic cancer with RLHA and portal vein (PV) invasion. Pancreatectomy (including total pancreatectomy in two cases and pancreatoduodenectomy in one case) with RLHA and PV reconstruction was performed. Three different techniques of arterial reconstruction that were suitable for the individual cases were used. They were: (1) end-to-end anastomosis between the CHA and the left hepatic artery (LHA) and end-to-end anastomosis between the middle hepatic artery (MHA) and the right hepatic artery (RHA), (2) end-to-end anastomosis between the left gastric artery (LGA) and the RHA and end-to-end anastomosis between the right gastroepiploic artery and the LHA, and (3) end-to-side anastomosis between the splenic artery (SA) and the LHA and end-to-end anastomosis between the SA and the RHA. RESULTS: The mean operating time was 735 min (range 686-800 min) and the mean blood loss was 1726 ml (range 1140-2230 ml). Microscopic curative resection (R0) was possible in all cases even if their International Union Against Cancer (UICC) stage was IIb. There was one case of wound infection, although no serious complications, including hepatic artery thrombosis, liver failure, or biliary fistula were observed. By follow-up three-dimensional computed tomography (3D-CT) angiography, the patency of the anastomosed artery was confirmed to be maintained in all three cases. CONCLUSIONS: R0 operation with 3 different arterial reconstruction techniques was able to be performed without presenting any risk.

Management of postoperative arterial hemorrhage after pancreato-biliary surgery according to the site of bleeding: re-laparotomy or interventional radiology.

BACKGROUND/PURPOSE: Intra-abdominal arterial hemorrhage is still one of the most serious complications after pancreato-biliary surgery. We retrospectively analyzed our experiences with 15 patients in order to establish a therapeutic strategy for postoperative arterial hemorrhage following pancreato-biliary surgery. METHODS: Between August 1981 and November 2007, 15 patients developed massive intra-abdominal arterial bleeding after pancreato-biliary surgery. The initial surgery of these 15 patients were pylorus-preserving pancreatoduodenectomy (PPPD) (7 patients), hemihepatectomy and caudate lobectomy with extrahepatic bile duct resection or PPPD (4 patients), Whipple's pancreatoduodenectomy (PD) (3 patients), and total pancreatectomy (1 patient). Twelve patients were managed by transcatheter arterial embolization and three patients underwent re-laparotomy. RESULTS: Patients were divided into two groups according to the site of bleeding: SMA group, superior mesenteric artery (4 patients); HA group, stump of gastroduodenal artery, right hepatic artery, common hepatic artery, or proper hepatic artery (11 patients). In the SMA group, re-laparotomy and coil embolization for pseudoaneurysm were performed in three and one patients, respectively, but none of the patients survived. In the HA group, all 11 patients were managed by transcatheter arterial embolization. None of four patients who had major hepatectomy with extrahepatic bile duct resection survived. Six of seven patients (85.7%) who had pancreatectomy survived, although hepatic infarction occurred in four. CONCLUSIONS: Management of postoperative arterial hemorrhage after pancreato-biliary surgery should be done according to the site of bleeding and the initial operative procedure. Careful consideration is required for indication of interventional radiology for bleeding from SMA after pancreatectomy and hepatic artery after major hepatectomy with bilioenteric anastomosis.

Serum amyloid A-positive hepatocellular neoplasms in the resected livers from 3 patients with alcoholic cirrhosis.

Twelve hepatocellular nodules were characterized in the resected livers from 3 patients (2 men and a woman) with alcoholic cirrhosis. Imaging techniques suggested that the nodules were hypervascular and may be hepatocellular carcinoma. Five nodules (4-31 mm in diameter) were serum amyloid A-positive hepatocellular neoplasm, which shares features with inflammatory hepatocellular adenoma. The remaining 7 nodules (5-8 mm) were focal nodular hyperplasia-like nodules showing focal or no immunostaining for serum amyloid A. The serum amyloid A-positive hepatocellular neoplasms showed increased cellular density, inflammatory infiltrate, sinusoidal dilatation, and ductular reaction to various degrees. These histologic features tended to be less extensive in focal nodular hyperplasia-like nodules. Three of 4 serum amyloid A-positive hepatocellular neoplasms showed slight hypointensity in the hepatobiliary phase on the magnetic resonance (MR) imaging with gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid (Gd-EOB-DTPA) enhancement. In contrast, 3 focal nodular hyperplasia-like nodules showed iso-intensity in the hepatobiliary phase. This study further confirms characteristics of serum amyloid A-positive hepatocellular neoplasm arising in alcoholic cirrhosis that share features with inflammatory hepatocellular adenomas. Serum amyloid A-positive hepatocellular neoplasms sometimes co-exist with focal nodular hyperplasia-like nodules and may show different findings on Gd-EOB-enhanced MR imaging.

Whereabouts of an internal short stent placed across the pancreaticojejunostomy following pancreatoduodenectomy.

BACKGROUND/PURPOSE: It is generally thought that an internal short stent placed across the pancreaticojejunostomy (PJ) following pancreatoduodenectomy (PD) usually passes spontaneously through the rectum thereafter; however, we experienced some patients who presented with pancreatitis and cholangitis owing to delayed defecation of the stent. The purpose of this study was to clarify when the stent eventually became detached from the PJ and how it passed through the body until it was finally defecated. In addition, we also investigated the factors that may prevent such detachment and defecation. METHODS: This study retrospectively analyzed 57 patients who had had internal short stents placed across the PJ following PD. Defecation from the body, detachment from the PJ, and distal migration of the stent was confirmed by X-ray or computed tomography (CT) during the postoperative course. The cumulative rates of defecation and detachment of the stents, complications in relation to delayed defecation of the stents, and factors predictive of the delayed defecation, delayed detachment, and distal migration of the stents were analyzed. RESULTS: Defecation of the stent was confirmed in 35 patients. The median time to defecation after PD and the cumulative defecation rate at 1 year were 454 days and 41 %, respectively. Acute pancreatitis occurred in 2 patients with the stent remaining in the pancreatic duct. One patient experienced acute cholangitis owing to migration of the stent to the bile duct. Multivariate analysis showed that ≥5 stitches in the duct-to-mucosa anastomosis, stent size of ≥5 Fr, and pancreatic fistula classified as either Grade B or C were independent predictive factors for delayed defecation of the stent. Five or more stitches in the duct-to-mucosa anastomosis was an independent predictive factor for delayed detachment of the stent. A stent size of ≥5 Fr was a risk factor for distal migration of the stent. CONCLUSION: In more than half of the study patients, internal short stents were not defecated within 1 year. Retrieval of the stent should be considered following the migration of an internal short stent. A stent size of ≥5 Fr was an independent predictive factor for delayed defecation and distal migration of a stent. Five or more stitches in the duct-to-mucosa anastomosis was an independent predictive factor for delayed defecation and detachment of a stent.

Small nodules which could indicate the early phase of autoimmune pancreatitis.

We present a case with small pancreatic nodules, which could indicate the early phase of autoimmune pancreatitis (AIP). A 68-year-old man was referred to our hospital for further diagnostic evaluation of a pancreatic mass detected on abdominal ultrasonography screening for epigastric discomfort. Abdominal ultrasonography and endoscopic ultrasonography revealed a low echoic lesion measuring approximately 1 cm with an irregular margin in the body of the pancreas. Computed tomography revealed a tumor in the portal venous phase of enhancement; hence, a distal pancreatectomy was performed. On histology, a marked lymphocyte- and plasma cell-dominant inflammatory cell infiltrate was observed in the nodule. There was another smaller nodule consisting of moderate lymphoplasmacytic infiltration in the 2-cm distal portion of the pancreas. Lymphoplasmacytic infiltration was also observed around the main pancreatic duct in the pancreatic stump. In the parenchyma, other than these 3 portions, the normal lobular structure was well preserved. Little storiform fibrosis and obliterative phlebitis were observed in the resected specimen. On immunohistochemical staining, plasma cells showing strong immunoreactivity for immunoglobulin G4 were observed within these two nodules and around the main pancreatic duct at the cut surface. This case could indicate the early phase and multicentricity of AIP.

Eleven cases of postoperative hepatic infarction following pancreato-biliary surgery.

BACKGROUND: Postoperative hepatic infarction is rare; therefore, clinical characteristics and outcomes of postoperative hepatic infarction after pancreatobiliary surgery have not been obvious. METHODS: Eleven patients encountered hepatic infarction after pancreato-biliary surgery. Management, clinical course, and outcome of these 11 patients were retrospectively analyzed. RESULTS: Possible causes of the hepatic infarction were inadvertent injury of the hepatic artery during lymph node dissection in five patients, right hepatic artery ligation in two patients, long-term clamp of the hepatic artery during hepatic arterial reconstruction in two patients, suturing for bleeding from the right hepatic artery in one patient, and celiac axis compression syndrome in one patient. Five of the 17 infarcts extended for one whole section of the liver, and distribution of the other 12 was less than one section. Ten patients discharged from hospital; however, one patient died of sepsis of unknown origin. CONCLUSIONS: Attention should be paid to inadvertent injury of hepatic artery to prevent hepatic infarction. Hepatic infarctions after pancreato-biliary surgery seldom extend to the entire liver and most of them are able to be treated without intervention.