Combined pancreaticoduodenectomy for advanced gallbladder cancer: Indications, surgical outcomes, and limitations.

BACKGROUND: This study aimed to elucidate the clinical value of combined pancreaticoduodenectomy (PD) for advanced gallbladder cancer according to the mode of cancer spread in the pancreaticoduodenal region. METHODS: Patients who underwent combined PD for advanced gallbladder cancer were retrospectively reviewed. The mode of cancer spread in the pancreaticoduodenal region was defined as involvement of peripancreatic organs/structures alone, peripancreatic nodal metastasis alone, or both. Surgical outcomes were compared among these modes of spread. RESULTS: Fifty-seven patients were included. Rates of severe morbidity and mortality were 52.6% and 3.5%, respectively. The mode of cancer spread was involvement of peripancreatic organs/structures alone in 16 patients, peripancreatic nodal metastasis alone in 17, and both in 24; R0 resection rates differed significantly among the groups (87.5% vs. 94.1% vs. 37.5%; p < 0.001). Overall survival (OS) was significantly worse in patients with both modes of spread (5-year OS, 8.3%) than in those with involvement of peripancreatic organs/structures alone (5-year OS, 37.9%; p < 0.001) and those with peripancreatic nodal metastasis alone (5-year OS, 29.4%; p = 0.011). OS was similar between pM0 patients with both modes of spread and pM1 patients (5-year OS, 16.7% vs. 8.7%; p = 0.605). Multivariate analysis identified mode of cancer spread as an independent prognostic factor (p = 0.006). CONCLUSIONS: Combined PD could be oncologically justified for advanced gallbladder cancer with involvement of peripancreatic organs/structures alone or peripancreatic nodal metastasis alone in the pancreaticoduodenal region. This procedure would not be indicated in patients with both modes of spread.

Extent of regional lymphadenectomy and number-based nodal classification for non-ampullary duodenal adenocarcinoma.

BACKGROUND: This study aimed to evaluate the adequate extent of regional lymphadenectomy according to tumor location and the impact of number-based nodal classification on survival in patients with non-ampullary duodenal adenocarcinoma (NADAC). METHODS: A total of 85 patients with NADAC who underwent surgery were enrolled. The frequency of metastasis was calculated for each node group in the respective tumor locations for 63 patients who underwent lymphadenectomy for pT2-pT4 tumor. RESULTS: The frequency of metastasis in the pancreaticoduodenal (nos. 13 and 17) and superior mesenteric artery (no. 14) nodes was high (16.7 %-52.3 %) regardless of tumor location. Metastasis in the perigastric (nos. 3 and 4d) and right celiac artery (no. 9) nodes was not uncommon (14.3 %-22.2 %) for tumors in the first portion. The frequency of metastasis in the pyloric (nos. 5 and 6) and the other peripancreaticoduodenal (nos. 8 and 12) nodes varied depending on tumor location but could not be ignored for staging. When these nodes were classified as regional nodes, the 5-year survival in patients with pN0, pN1 (1-2 positive nodes), and pN2 (≥3 positive nodes) were 82.9 %, 51.7 %, and 19.2 %, respectively (p < 0.001). pN classification independently predicted survival (pN1, p = 0.022; pN2, p < 0.001). CONCLUSIONS: Nos. 5, 6, 8, 12, 13, 14, and 17 nodes in all advanced NADAC and nos. 3, 4d, and 9 nodes in advanced NADAC in the first portion should be considered as regional nodes for accurate staging. The number-based nodal classification allows good patients' prognostic stratification.

Laparoscopic right hemicolectomy for a patient with idiopathic retroperitoneal fibrosis: A case report.

A 62-year-old man with abdominal pain and lumbago was admitted to our hospital. Blood examination revealed renal insufficiency, and CT revealed retroperitoneal fibrosis causing bilateral hydrocele and ureteral compression. A colonoscopy was performed to rule out secondary retroperitoneal fibrosis due to malignancies, and this imaging revealed an ascending colon cancer. Laparoscopic right hemicolectomy with lymphadenectomy and retroperitoneal biopsy were performed. The retroperitoneum was filled with hard, white fibrous tissue, which made it difficult to mobilize the right mesocolon from the retroperitoneum. Devascularization performed before mobilization allowed for a safe and oncologically feasible procedure. Histologically, there were no malignant cells in the retroperitoneal tissue. The patient has been without colon cancer reoccurrence for 4 years. When the surgical challenges that distinguish these patients from ordinary cases are recognized preoperatively, laparoscopic colectomy may be a feasible option for patients with colorectal cancer with idiopathic retroperitoneal fibrosis.

Diagnosis of ischemic small bowel disease by measurement of serum intestinal fatty acid-binding protein in patients with acute abdomen: a multicenter, observer-blinded validation study.

BACKGROUND: Intestinal fatty acid-binding protein (I-FABP) is a low-molecular-mass (15 kDa) cytosolic protein found exclusively in the epithelial cells of the small bowel mucosa. We aimed to evaluate the clinical usefulness of serum I-FABP measurement for the diagnosis of ischemic small bowel disease. METHODS: Patients with a clinical diagnosis of acute abdomen were recruited for this multicenter trial at one university hospital and nine city hospitals over a 13-month period. Serum I-FABP levels were measured in 361 eligible patients by an enzyme-linked immunosorbent assay using a specific monoclonal antibody. RESULTS: Of the 361 patients, 242 underwent surgery, and small bowel ischemia was diagnosed in 52 patients. The mean serum I-FABP level in the patients with small bowel ischemia was 40.7 ± 117.9 ng/ml, which was significantly higher than that in patients with non-ischemic small bowel disease (5.8 ± 15.6 ng/ml) and those with non-small bowel disease (1.8 ± 1.7 ng/ml). The serum I-FABP cutoff level for the diagnosis of small bowel ischemia was 3.1 ng/ml. Serum I-FABP was more efficient than conventional biochemical markers, in terms of sensitivity and positive and negative predictive values, in the diagnosis of small bowel ischemia. However, its specificity was slightly lower than that of creatinine phosphokinase or lactate dehydrogenase. The positive and negative likelihood ratios of serum I-FABP were 3.01 and 0.29, respectively. CONCLUSION: Serum I-FABP measurement is a non-invasive method that is potentially useful for the efficient identification of patients with acute abdomen who are at risk of small bowel ischemia.

[A case of advanced gastric cancer with multiple liver metastases successfully treated with TS-1 and CDDP].

A Case of Advanced Gastric Cancer with Multiple Liver Metastases Successfully Treated with TS-1 and CDDP: Akihiro Tsukahara, Kazuhiro Kaneko and Syuji Tanaka (Dept. of Surgery, Niigata Prefectural Koide Hospital) Summary A 70-year-old advanced gastric cancer patient with liver and lymph node metastases was treated by chemotherapy with TS-1 and CDDP. One course consisted of administration of TS-1 100 mg/body for 21 days followed by 14 days rest and infusion of CDDP 80 mg/body on day 8. At the end of 2 courses, the primary tumor showed a hypertrophic wall, but a partial response of the liver metastases (reduction ratio was 78.3%) and a complete response of the LN metastasis were achieved. PR and CR were maintained after 4 courses. There were no remarkable side effects for 4 courses. This chemotherapy may have therapeutic efficacy in cases of advanced gastric cancer with liver and lymph node metastases.

Thrombopoietin levels and peripheral platelet counts following living related donor liver transplantation.

BACKGROUND/AIMS: Thrombopoietin is the primary hematopoietic growth factor. Thrombopoietin deficiency may cause thrombocytopenia in advanced liver disease. The aim of our study was to investigate the relevance of thrombopoietin levels to peripheral platelet counts in patients with liver disease who underwent LRDLT (living related donor liver transplantation). METHODOLOGY: We divided the six patients who underwent LRDLT into two groups. Group 1 had thrombocytopenia and group 2 had normal platelet counts. We measured serum thrombopoietin and peripheral platelet counts before and after LRDLT. RESULTS: Pre-LRDLT thrombopoietin and peripheral platelet counts were lower in group 1 than in group 2. Thrombopoietin in group 1 significantly increased on the first day after LRDLT and peripheral platelet counts in group 1 increased following the rise in thrombopoietin (p < 0.05). Moreover, a marked increase in thrombopoietin and peripheral platelet counts was found in splenectomized patients during LRDLT. CONCLUSIONS: These findings suggested inadequate thrombopoietin production in advanced stage liver disease which caused thrombocytopenia. Improvement of thrombopoietin production in graft liver function may contribute to increase of peripheral platelet counts.

[A case of advanced gastric cancer treated with paclitaxel and TS-1].

We treated a case of advanced gastric cancer with paclitaxel and TS-1. A 64-year-old man underwent total gastrectomy, splenectomy, and D2 + No. 16 a 2, b 1 lymph node (LN) dissection for gastric cancer. Computed tomography (CT) revealed metastases of supraclavicular and para-aortic LNs in the 4th postoperative month. Paclitaxel 90 mg was infused once a week, and TS-1 100 mg was administered daily. One course consisted of infusion of paclitaxel for 3 weeks followed by 2 weeks rest and administration of TS-1 for 4 weeks followed by 2 weeks rest. At the end of 4 courses of paclitaxel and 3 courses of TS-1, a partial response of the supraclavicular LN metastasis and a complete response of the para-aortic LN metastasis were achieved. There were no remarkable side effects for 2 years after the operation. This chemotherapy might be suitable to treat patients with LN metastases of advanced gastric cancer.

Splenectomy for reduction of excessive portal hypertension after adult living-related donor liver transplantation.

BACKGROUND/AIMS: We investigated the effects of splenectomy on the reduction of excessive portal hypertension immediately after adult living-related donor liver transplantation, paying particular attention to peritransplanted portal pressure in seven adult patients. METHODOLOGY: We studied the relationship between portal hypertension and hyperbilirubinemia in small-for-size graft liver transplantation. RESULTS: In the three cases, the portal pressures increased beyond 30 cmH2O after living-related donor liver transplantation, despite the right lobe graft, and these patients underwent splenectomy. After splenectomy, their portal pressures decreased below 25 cmH2O. The portal pressure underwent auxiliary orthotopic partial liver transplantation due to the hypercitrullinemia and did not change after surgery (9.5 to 11.5 cmH2O). Interestingly, the hyperbilirubinemia occurring after living-related donor liver transplantation were as the primary result of direct bilirubin except for the patient with citrullinemia. The posttransplanted portal pressures were controlled below 25 cmH2O in all patients, with their peak serum total bilirubin levels not exceeding 15 mg/dL, and the patients were discharged without major complications. Three patients underwent splenectomy, and did not suffer from serious infection. The reduction in excessive portal hypertension after living-related donor liver transplantation might prevent liver injury and post-transplant hyperbilirubinemia. CONCLUSIONS: However, splenectomy remains a life-threatening factor. Therefore, transplant surgeons encountering living-related donor liver transplantation must continue to seek out additional solutions to problems with excessive portal hypertension.

[Dormant chemotherapy by low-dose FP and low-dose UFT-E in recurrent gastric cancer with long-term survival--a case report].

We experienced a case of recurrent gastric cancer with a long-term survival. A 64-year-old man was admitted to the hospital for advanced gastric cancer in the upper stomach. Abdominal CT scan revealed para-aortic lymph nodal metastases. The patient underwent total gastrectomy, distal pancreatectomy, splenectomy, left adrenectomy, and left nephrectomy with D4 lymph node dissection, in what was a curability B resection. Conclusive findings were t2 (ss), n4, H0, P0, M0, and stage IVb. One year after the operation, para-aortic lymph node recurrence was evaluated. The patient was treated with low-dose cisplatin-5-FU therapy, and a partial response was observed and continued for over 2 years with an administration of UFT-E (300 mg/day). He died of repeated aggravation of para-aortic lymph node metastases 6 years and 2 months after the operation. We considered that the long-term survival of this patient was attributable to a 3-year tumor dormancy induced by low-dose cisplatin-5-FU therapy and administration of low-dose UFT.