Randomized clinical trial of 24 versus 72 h antimicrobial prophylaxis in patients undergoing open total gastrectomy for gastric cancer.

BACKGROUND: Open total gastrectomy carries a high risk of surgical-site infection (SSI). This study evaluated the non-inferiority of antimicrobial prophylaxis for 24 compared with 72 h after open total gastrectomy. METHODS: An open-label, randomized, non-inferiority study was conducted at 57 institutions in Japan. Eligible patients were those who underwent open total gastrectomy for gastric cancer. Patients were assigned randomly to continued use of ß-lactamase inhibitor for either 24 or 72 h after surgery. The primary endpoint was the incidence of SSI, with non-inferiority based on a margin of 9 percentage points and a 90 per cent c.i. The secondary endpoint was the incidence of remote infection. RESULTS: A total of 464 patients (24 h prophylaxis, 228; 72 h prophylaxis, 236) were analysed. SSI occurred in 20 patients (8·8 per cent) in the 24-h prophylaxis group and 26 (11·0 per cent) in the 72-h group (absolute difference -2·2 (90 per cent c.i. -6·8 to 2·4) per cent; P < 0·001 for non-inferiority). However, the incidence of remote infection was significantly higher in the 24-h prophylaxis group. CONCLUSION: Antimicrobial prophylaxis for 24 h after total gastrectomy is not inferior to 72 h prophylaxis for prevention of SSI. Shortened antimicrobial prophylaxis might increase the incidence of remote infection. Registration number: UMIN000001062 ( http://www.umin.ac.jp).

Selective versus total drainage for biliary obstruction in the hepatic hilus: an experimental study.

BACKGROUND: Controversy exists as to whether selective biliary drainage (SBD) or total biliary drainage (TBD) is preferable as a preoperative procedure before extended hemihepatectomy for hilar cholangiocarcinoma, especially with regard to the functional reserve of the future remnant liver. METHODS: SBD or TBD was performed after 1 week of total biliary obstruction in rats. In SBD, the biliary trees of the left lobes (approximately 70% of the liver) were kept obstructed, whereas the right lobes were drained selectively. Mitochondrial function and microsomal cytochrome content were examined before and 1, 2, and 4 weeks after drainage. RESULTS: The right lobes weighed significantly more after SBD than after TBD. There were no significant differences in mitochondrial function between the two groups. The microsomal cytochrome content per milligram of microsomal protein significantly decreased 1 week after biliary obstruction and then recovered to a similar extent after SBD and TBD in the right lobes. However, the total microsomal cytochrome content (nanomoles per 100 g body weight) and the overall rate of mitochondrial adenosine triphosphate synthesis (mmoles per minute per 100 g of body weight) in the right lobes 4 weeks after SBD were significantly greater than those after TBD. CONCLUSIONS: SBD is superior to TBD with regard to the functional reserve of the future remnant liver.

How should polypoid lesions of the gallbladder be treated in the era of laparoscopic cholecystectomy?

BACKGROUND: Definitive criteria for choosing the most appropriate treatment for each type of polypoid lesion of the gallbladder (PLG) have yet to be established. METHODS: The shapes, sizes, echo patterns, and echogenicities of PLGs that had been evaluated by means of ultrasonography in 72 patients who had undergone resective surgery were analyzed retrospectively to elucidate the ultrasonic characteristics of polypoid cancers and to establish criteria for selecting the most suitable treatment such as laparoscopic cholecystectomy for each type of PLG. RESULTS: Histologic examinations showed cholesterol polyps in 47 patients, adenomas in 8, cancers in 16, and an inflammatory polyp in 1. The diameters of 61% of the benign PLGs were less than 10 mm, whereas those of 88% of the cancers were more than 10 mm; 80% of the former were pedunculated and 56% of the latter were sessile. Seven of eight early-stage cancers had diameters less than 18 mm, whereas those of all eight more advanced cancers were greater than 18 mm. Five of the eight early-stage cancers were pedunculated, and six of the eight more advanced cancers were sessile. Cholecystectomy with or without full-thickness dissection were main surgical procedures used to resect benign PLGs and early-stage cancers, whereas cholecystectomy with partial liver resection was used for more advanced cancers. Laparoscopic cholecystectomy was performed in the recent 34 patients, four of whom had early-stage cancers. CONCLUSIONS: A PLG with a diameter of less than 18 mm is a potential early-stage cancer and therefore can be resected by laparoscopic cholecystectomy with full-thickness dissection. However, when cancer invades the subserosal layer or beyond, a second-look operation is necessary. A PLG with a diameter of greater than 18 mm may be an advanced cancer and should be removed by using cholecystectomy with partial liver resection or a more extended procedure with lymph node dissection.

Mesenteric arterioportal shunt after hepatic artery interruption.

BACKGROUND: Massive hepatic necrosis from hepatic artery (HA) interruption is a complication after extended pancreatobiliary operation. The effectiveness of a mesenteric arterioportal shunt in preventing liver failure after massive hepatic necrosis was evaluated. METHODS: Of 98 patients who underwent pancreatic or hepatic resection for pancreatobiliary carcinoma between January 1989 and December 1995, six received a mesenteric arterioportal shunt. Clinical and hemodynamic analyses were done retrospectively. RESULTS: The six patients were classified into groups: A, postoperative hepatic arterial occlusion and, B, main HA excision without reconstruction. One patient in group A and three patients in group B had good arterioportal shunt patency and favorable clinical courses. However, fatal hepatic necrosis after ligation of the HA proper occurred in one patient in group A from small portal flow despite a presumed patent shunt. In another patient in group A angiogram revealed shunt occlusion. CONCLUSIONS: A mesenteric arterioportal shunt is beneficial when massive hepatic necrosis has occurred or is expected after main HA interruption under such conditions as postoperative hepatic arterial occlusion or HA excision without reconstruction. The procedure has the advantages of appropriate selection of artery size, a lower abdominal site apart from the primary operative field, and easy shunt closure by transarterial embolization.

Risk factors for hyperamylasemia after hepatectomy using the Pringle maneuver: randomized analysis of surgical parameters.

OBJECTIVES: To determine whether the increased portal venous pressure caused by use of the Pringle maneuver contributes to inducing posthepatectomy hyperamylasemia and, subsequently, to evaluate risk factors for its development. DESIGN: Randomized study. SETTING: University hospital. PATIENTS: Forty patients who were going to undergo hepatectomy were assigned prospectively to either a superior mesenteric artery clamp (n=20) or a nonclamp (n=20) group by the random-block method. INTERVENTIONS: The Pringle maneuver was used during hepatectomy, and in the superior mesenteric artery clamp group the superior mesenteric arteries were clamped simultaneously. MAIN OUTCOME MEASURES: Amylase activity, isozyme, and creatinine levels in the blood and urine samples were measured before and after surgery, and the amylase creatinine clearance ratio was estimated. RESULTS: The serum amylase activity levels of the superior mesenteric artery clamp and nonclamp groups did not differ significantly during the 7 postoperative days. The serum amylase activity levels exceeded 250 U/L in 14 patients (group 1) and remained below this level in 26 (group 2). The salivary-type isozyme levels of group 1 increased significantly compared with those of group 2, and the levels of group 2 remained normal. The total amount of amylase excreted in the urine samples of group 1 patients also increased significantly, with the salivary-type isozyme predominating. All the mean amylase creatinine clearance ratios before and after surgery remained normal. The mode chi2 of the logistic model including the indocyanine green retention rate at 15 minutes and the ratio of the resected liver weight to the whole liver volume showed a significantly increased risk (P=.01). CONCLUSION: It is not the increased portal venous pressure caused by use of the Pringle maneuver but the liver function and the extent of liver resection that are considered risk factors for inducing posthepatectomy salivary-type hyperamylasemia.

Extended right trisegmentectomy for hilar bile duct carcinoma.

Extended right trisegmentectomy with total caudate lobectomy, extrahepatic bile duct resection and lymphadenectomy was performed for a 54-year-old man, who was diagnosed as type IV hilar bile duct carcinoma. After division of the right portal vein and all the portal venous branches to the caudate lobe and the left medial segment, the left hepatic artery and its branches to the segment II and III were dissected from the corresponding bile ducts to about 1 cm beyond the left margin of the umbilical portion of the left portal vein, where the lateral segmental bile ducts were divided after transection of the hepatic parenchyma. All bile duct margins were free from cancer microscopically. To our knowledge this is the first report of extended right trisegmentectomy for hilar bile duct carcinoma, in which the bile ducts of the left lateral segment are divided at the left side of the umbilical portion of the left portal vein. This technique facilitates making the intrahepatic bile duct stumps free from cancer. However, its impact on long-term survival remains to be determined.

Proposal on the extent of lymph node dissection for gallbladder carcinoma.

BACKGROUND/AIMS: To evaluate the value of performing extended regional lymph node dissection for gallbladder carcinoma, the mode of recurrence after curative resection was analyzed. METHODOLOGY: Records of 45 patients who underwent surgical resection for gallbladder carcinoma from 1973 to August 1997 were reviewed. RESULTS: Thirty-three cases underwent a curative resection and 12 received a non-curative resection. Among the 32 patients who survived the curative resection, cancer recurred in 7 with lymph node metastasis, whereas recurrence was found in only 1 of the remaining 25 patients without lymph node metastasis (p < 0.0001). At the 1st diagnosis of recurrence in these 8 patients, lymph node recurrence was detected in 7, and the site of recurrence was limited to the lymph nodes, which were confined to the peripancreatic region and the interaortocaval nodes near the left renal vein in 4 cases. CONCLUSIONS: In view of the site of the metastatic lymph nodes and the lymphatic drainage system of the gallbladder, it was considered that lymph node dissection was inadequate in 5 of the 8 patients and that 2 might have been cured by extended regional lymph node dissection, including complete resection of the retroportal, posterior pancreatoduodenal, right celiac and interaortocaval nodes.

Tumor angiogenesis in gallbladder carcinoma.

BACKGROUND/AIMS: Neovascularization of tumor tissue has been proposed to be essential for tumor growth, proliferation and, eventually, metastasis. Although the microvessel count in some kinds of solid tumor was shown to correlate with clinical outcome, little is known about its significance in gallbladder carcinoma. METHODOLOGY: In order to determine whether tumor angiogenesis is a prognostic factor in gallbladder carcinoma patients, microvessels in selected areas (a 200x field, 0.74 mm2) in specimens resected from 40 patients with gallbladder carcinomas were identified by immunostaining endothelial cells for the endothelial antigen CD34 and counted. RESULTS: Univariate analysis showed a relationship between the microvessel count and survival (p=0.04), but multivariate analysis revealed that the microvessel count was not an independent prognostic factor (p=0.256). Although it correlated with the lymph node status (p=0.044), it bore no relation to tumor status or clinical stage. CONCLUSIONS: These results indicate that participation of neovascularization in gallbladder cancer spread is minor, especially during the early course.

Septic cholangitis occurring 11 years after inadvertent ligation of the right hepatic duct during cholecystectomy: a case report.

We report a case of acute cholangitis caused by the inadvertent ligation of the right hepatic duct during a cholecystectomy performed 11 years before. When the condition of the right hepatic duct or accessory bile duct ligation persists for more than several years, resulting in atrophy of the relevant part of the liver, bile duct ligation will rarely cause severe clinical problems. However, acute cholangitis may occur, as in our patient, so long-term follow-up of the patient is warranted.

Surgery of icteric-type hepatoma after biliary drainage and transcatheter arterial embolization.

BACKGROUND/AIMS: The authors aimed to study the importance of pre-operative jaundice reduction in the surgical treatment of icteric-type hepatoma (IHCC). METHODOLOGY: A series of 10 patients with IHCC was reviewed. Eight out of the 10 patients underwent biliary drainage. Obstructive jaundice in the other 2 patients resolved spontaneously. Nine patients subsequently underwent transcatheter arterial embolization (TAE), which appeared to have an additional effect in reducing jaundice. RESULTS: Consequently, 9 of the 10 patients achieved sufficient reduction of the jaundice preoperatively. After the evaluation of liver function, 8 patients underwent hepatectomy without any appreciable morbidity or mortality. The median survival time of the resected cases was 18 months. CONCLUSIONS: A combination of biliary drainage and subsequent TAE is a recommended pre-operative strategy for the successful surgical treatment of IHCC.

US guided biliary drainage during hepatopancreatico-jejunostomy for diffuse bile duct carcinoma.

Liver failure is one of the principal causes of post-operative morbidity and mortality after major hepatectomy for diffuse bile duct cancer. To prevent this complication, biliary decompression must be guaranteed before and during the operation. If a nasobiliary catheter is positioned pre-operatively, biliary drainage can be maintained during hepatopancreato-duodenectomy by introducing a transhepatic drain under sonographic guidance. This original technique is described herein.

A new porto-systemic bypass technique for hepatopancreatoduodenectomy with portal vein resection.

When reconstructing the portal vein (PV) following hepatopancreatoduodenectomy (HPD) with PV resection, a new porto-systemic bypass (PSB) technique can be employed to prevent intestinal vascular congestion. The Whipple procedure is performed in a standard manner, as long a portion of the gastrocolic trunk is preserved for insertion of an antithrombogenic catheter (ATC). After harvesting the left external iliac vein and exposing the right great saphenous vein, the end of the ATC is inserted in the superior mesenteric vein via the gastrocolic trunk in the distal direction and the other end of the ATC is inserted in the greater saphenous vein. PSB is achieved as a result of the venous pressure gradient. By employing this technique, an ATC can be inserted without damaging another mesenteric venous branch and with minimal damage to the endothelium, and the small intestine is not exposed in the operative field until enteric reconstruction is started. This technique is a promising option for PSB during HPD with PV resection.

Laparoscopic cholecystectomy with full-thickness dissection for potentially cancerous lesions: comparison with standard technique.

BACKGROUND/AIMS: With an increase in laparoscopic cholecystectomy (LC) cases, unsuspected gallbladder cancers have been reported and intraabdominal cancer dissemination has been identified as a crucial problem. Since September 1991, we employed LC with full-thickness dissection (LC-F) for polypoid lesions of the gallbladder. In the present study, the utility of the procedure was investigated. METHODOLOGY: For 261 patients who underwent standard LC (S-LC) or LC-F between September 1991 and August 1996, the operation time, intra- and post-operative complications relevant to the operative technique, histological findings of the gallbladders, and prognosis of each patient with gallbladder cancer were evaluated. RESULTS: S-LC and LC-F were performed in 231 and 30 patients, respectively. The mean operation times for S-LC and LC-F were 157 and 120 min, respectively, (p < 0.05). Gallbladder perforation occurred in 29 S-LCs, whereas there was none in 30 LC-Fs (p < 0.05). Bleeding from the gallbladder bed occurred in 1 patient in each of the 2 groups, but was stopped easily. There was neither post-operative bleeding nor bile leakage in either group. Mucosal cancer was diagnosed in 3 gallbladders resected by S-LC and 1 resected by LC-F. One patient of the LC-F group with advanced cancer underwent laparotomy. All the patients have no signs of recurrence. CONCLUSIONS: LC-F allows the complete removal of the connective tissue of the gallbladder bed without perforation and, therefore, is considered as a safe and useful procedure for resecting gallbladders with potentially cancerous lesions.

Ventral dissection of replaced right hepatic artery during pancreatoduodenectomy.

A novel technique for dissecting a replaced right hepatic artery during pancreatoduodenectomy in patients with middle or lower bile duct carcinoma is presented. After skeletonizing the left, proper, common hepatic arteries and the portal vein, the replaced right hepatic artery is dissected from the ventro-medial side of the hepatoduodenal ligament by severing the thin connective tissue behind the portal vein. Thus the hepatic arteries and the portal vein are completely isolated without the Kocher maneuver, leaving the cancer and the bile duct untouched en bloc with the surrounding lymph nodes and the pancreas head. The periaortic lymph nodes can also be resected en bloc with the main lesion.

[Improving the anti-tumor activity of 5-fluorouracil by methotrexate].

The first clinical application of biochemical modulation (BCM) of 5-fluorouracil (5-FU) was the sequential MTX/5-FU regimen proposed in 1977 by Bertino for the treatment of colorectal cancer. In Japan, sequential MTX/5-FU therapy was mainly used as a new method of treating gastric cancer, and attracted a great deal of attention because it proved effective in many cases of advanced gastric cancer that had been unresponsive to the previous chemotherapy, particularly scirrhous gastric cancer with poor prognosis. Its therapeutic efficacy varied according to histologic type, it was effective in cases of peritoneal dissemination and disseminated intravascular coagulopathy (DIC), it was associated with fewer adverse effects, and it was a multidrug chemotherapy based on a clear rationale. With sequential MTX/5-FU therapy as a starting point, fundamental studies of BCM and its clinical applications have expanded rapidly in Japan. This paper provides an outline of sequential MTX/5-FU therapy from the aspects of its mechanism of action, indications, therapeutic efficacy, relevance to adjuvant therapy, counter-measures to adverse effects, and emergence of resistance to the drugs involved. The high therapeutic efficacy of this therapy in certain histologic types is also discussed, and its combined use with other forms of BCM, as in triple BCM (LV/5-FU + CDDP/5-FU + MTX/5-FU), is introduced.

[Indication and outcome of extended right hemihepatectomy combined with pancreatoduodenectomy for bile duct carcinoma].

During the past 10 years, we have performed extended right hemihepatectomy combined with pancreatoduodenectomy (rtHPD) in eight patients with bile duct carcinoma. We compared the results in these patients with those in 43 bile duct carcinoma patients who underwent extrahepatic bile duct resection with more extensive hepatectomy than hemihepatectomy. Our indication for rtHPD is bile duct carcinoma of the diffuse type involving the intrapancreatic bile duct. For patients with obstructive jaundice, biliary drainage was performed preferentially in the part of the liver to be preserved. Portal vein embolization was performed before extended right hemihepatectomy or left trisectorectomy. Complete external drainage of pancreatic juice followed by second-stage pancreatojejunostomy was performed in five rtHPD patients. There were no hospital deaths or hepatic failures. There were four 5-year survivors after rtHPD. There was no significant difference between the cumulative 5-year survival rates after rtHPD (71%) and non-HPD (42%). Patients with bile duct carcinoma whose prognosis can be improved only by rtHPD exist and should be treated by rtHPD. However, considering the reported high mortality rate after this procedure, rtHPD should not be performed in an institution where its safety cannot be guaranteed.

Abdominal tuberculoma mimicking a pancreatic neoplasm: report of a case.

We report herein a case of clinically solitary abdominal tuberculoma. A 28-year-old woman was admitted to hospital for treatment of an abdominal tumor shown to be located in the head of the pancreas and compressing the superior mesenteric vein by echosonography and computed tomography (CT). There were no clinical signs or symptoms of tuberculosis in the lungs or abdomen. Thus, under the diagnosis of a neoplasm of the pancreas, an exploratory laparotomy was performed which revealed tuberculosis. The patient made an excellent recovery on anti-tuberculous treatment, and no evidence of a tumor was seen on a CT scan performed 6 months after the initiation of treatment. Abdominal tuberculoma is often mistaken for a malignant neoplasm and the nonsurgical diagnosis of this entity continues to be a challenge.