Dynamics of the prognostic nutritional index in preoperative chemotherapy in patients with colorectal liver metastases.

BACKGROUND: Identifying the prognostic indicators that reflect the efficacy of preoperative chemotherapy is necessary. In this study, we investigated the prognostic indicators targeting the systemic inflammatory response for the administration of preoperative chemotherapy in patients with colorectal liver metastases. METHODS: Data for 192 patients were retrospectively analyzed. The relationship between overall survival and clinicopathological variables, including biomarkers such as the prognostic nutritional index, was investigated in patients who underwent upfront surgery or preoperative chemotherapy. RESULTS: In the upfront surgery group, extrahepatic lesion (p=0.01) and low prognostic nutritional index (p < 0.01) were significant prognostic indicators, whereas a decrease in the prognostic nutritional index (p=0.01) during preoperative chemotherapy were independent poor prognostic factors in the preoperative chemotherapy group. In particular, a decrease in the prognostic nutritional index was a significant prognostic marker in patients aged <75 years (p=0.04). In patients with a low prognostic nutritional index aged <75 years, preoperative chemotherapy significantly prolonged overall survival (p=0.02). CONCLUSION: A decrease in the prognostic nutritional index during preoperative chemotherapy predicted overall survival of patients with colorectal liver metastases after hepatic resection, and preoperative chemotherapy may be effective for patients aged <75 years with a low prognostic nutritional index.

Successful resection of port site recurrence of pancreatic ductal adenocarcinoma after laparoscopic distal pancreatectomy.

BACKGROUND: There are many reports of port site recurrence after laparoscopic surgery for various types of cancer. However, only two cases of port site recurrence after laparoscopic pancreatectomy have been reported to date. We herein report a case of port site recurrence after laparoscopic distal pancreatectomy. CASE PRESENTATION: A 73-year-old woman was diagnosed with pancreatic tail cancer and underwent laparoscopic distal pancreatectomy with splenectomy. Histopathological examination revealed pancreatic ductal carcinoma (pT1N0M0 pStage I). The patient was discharged on postoperative day 14 with no complications. However, 5 months after surgery, computed tomography showed a small tumor at the right abdominal wall. No distant metastasis had appeared after 7 months of follow-up. Under the diagnosis of port site recurrence without any other metastases, we resected this abdominal tumor. Histopathological examination showed port site recurrence of pancreatic ductal carcinoma. No recurrence was observed 15 months postoperatively. CONCLUSIONS: This is the report of successful resection of port site recurrence of pancreatic cancer.

D1 Distal Pancreatectomy for Left-sided Pancreatic Ductal Adenocarcinoma Is Justifiable: A Propensity-score Matched Multicenter Study.

BACKGROUND/AIM: Evidence on the optimal extent of lymph node dissection for left-sided pancreatic ductal adenocarcinoma (PDAC) is scarce. The aim of the current study was to compare the long-term outcomes of patients who underwent D1 distal pancreatectomy (DP) with D2 DP for left-sided PDAC. PATIENTS AND METHODS: Patients undergoing DP for left-sided PDAC at the four institutions affiliated to The Jikei University were enrolled in this study. Patients were divided into D1 and D2 groups. Patients' clinical characteristics, overall survival (OS), and relapse-free survival (RFS) were compared between the two groups before and after propensity-score matched (PSM) analysis. RESULTS: Of 145 patients with left-sided PDAC, 55 patients underwent D1 DP and 90 underwent D2 DP, of whom 38 matched pairs were included in the PSM analytic cohort. In the unmatched cohort, no significant difference was found between the D1 and D2 groups for both OS (median 2.51 vs. 3.07 years; p=0.709) and RFS (median 1.47 vs. 1.27 years; p=0.565). After PSM, OS (median 2.37 vs. 3.56 years; p=0.407) and RFS (median 1.35 vs. 1.11 years; p=0.542) were not significantly different between the two groups. In a comparison of regional and systemic recurrence sites, no significant difference was observed between the two groups (p=0.500). CONCLUSION: The long-term survival of D1 DP for left-sided PDAC was not inferior to D2 DP. In an era in which the importance of multidisciplinary treatment for PDAC has been documented, unnecessary extended surgery should be avoided.

Ischemic small bowel perforation caused by cholesterol crystal embolism following transcatheter arterial chemoembolization for recurrent hepatocellular carcinoma: a case report.

BACKGROUND: Cholesterol crystal embolism (CCE) following transcatheter arterial chemoembolization (TACE) is rare. CASE PRESENTATION: A 71-year-old man underwent TACE for recurrence of hepatocellular carcinoma (HCC). On postoperative day (POD) 5, he developed abdominal pain and fever. Computed tomography revealed intraperitoneal free air. The patient was diagnosed with gastrointestinal perforation with peritonitis, for which partial intestinal resection and covering ileostomy were performed. Histological examination revealed perforation of the small intestine caused by CCE. The patient made a satisfactory recovery and was discharged on POD 30. The patient showed no recurrence of cholesterol crystal embolism or HCC for 2 years after surgery. CONCLUSION: We reported a successfully treated case of ischemic small bowel perforation due to cholesterol crystal embolism following transcatheter arterial chemoembolization for recurrent HCC.

Assessment of Outcome of Hepatic Resection for Extremely Elderly Patients With a Hepatic Malignancy.

BACKGROUND/AIM: We aimed to assess surgical outcome and long-term survival after elective hepatic resection for hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM) in patients aged 80 years or older. PATIENTS AND METHODS: This study included 100 patients aged 70 years or older, who underwent hepatic resection for HCC or CRLM between January 2000 and December 2012. Outcomes and clinicopathological data were compared between the elderly (aged 70-79 years; n=84) and extremely elderly groups (aged 80 years or older; n=16). RESULTS: Incidence of postoperative complications, in-hospital mortality, and postoperative OS in the extremely elderly group were comparable with those of the elderly group. In patients with HCC, the extremely elderly group was associated with shorter DFS (p=0.030) in univariate analysis, while multivariate analysis showed significant and independent factors of cancer recurrence. CONCLUSION: Hepatic resection for HCC and CRLM in patients aged 80 years and older may be safe and acceptable with appropriate selection. For HCC in patients aged 80 years and older, hepatic resection may be effective when negative surgical margins can be achieved.

Risk Factors for Deterioration of Remnant Liver Function After Hepatic Resection for Hepatocellular Carcinoma.

BACKGROUND/AIM: After primary resection of hepatocellular carcinoma (HCC), the impact of patient's characteristics at the initial hepatectomy, on long-term remnant liver function has not been reported. The aim of this study was to identify factors associated with the deterioration of remnant liver function among patients who developed recurrent HCC. PATIENTS AND METHODS: A total of 51 patients with intrahepatic recurrence after initial hepatic resection for HCC were included. We retrospectively investigated the relation between patient characteristics and the degree of deterioration of remnant liver function upon recurrence. RESULTS: In univariate analysis, significant predictors of deterioration of remnant liver function consisted of preoperative gastro-esophageal varices (p=0.0101), preoperative transcatheter arterial chemoembolization (p=0.0230) and hepatectomy beyond Makuuchi's criteria (p=0.0101). In multivariate analysis, the only significant independent predictor of deterioration of remnant liver function was hepatectomy beyond Makuuchi's criteria (p=0.0498). CONCLUSION: Hepatectomy beyond Makuuchi's criteria at the initial hepatectomy may predict deterioration of remnant liver function upon recurrence of HCC.

Assessment of Outcome of Hepatic Resection for Extremely Elderly Patients With a Hepatic Malignancy.

BACKGROUND/AIM: We aimed to assess surgical outcome and long-term survival after elective hepatic resection for hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM) in patients aged 80 years or older. PATIENTS AND METHODS: This study included 100 patients aged 70 years or older, who underwent hepatic resection for HCC or CRLM between January 2000 and December 2012. Outcomes and clinicopathological data were compared between the elderly (aged 70-79 years; n=84) and extremely elderly groups (aged 80 years or over; n=16). RESULTS: Incidence of postoperative complications, in-hospital mortality, and postoperative OS in the extremely elderly group were comparable with those of the elderly group. In patients with HCC, the extremely elderly group was associated with shorter DFS (p=0.030) in univariate analysis, while multivariate analysis showed significant and independent factors of cancer recurrence. CONCLUSION: Hepatic resection for HCC and CRLM in patients aged 80 years and over may be safe and acceptable with appropriate selection. For HCC in patients aged 80 years and over, hepatic resection may be effective when negative surgical margins can be achieved.

Double Percutaneous Transesophageal Gastrotubing for Gastric Cancer: A Pilot Study.

BACKGROUND: The management of gastric cancer causing gastric outlet obstruction and dilatation must include decompression of the stomach and intravenous nutrition. Percutaneous transesophageal gastrotubing (PTEG) is an effective technique for either gastric decompression or enteral nutrition. Here, we investigated the efficacy and safety of double PTEG (dPTEG), that is, using PTEG for both purposes simultaneously, in patients with gastric cancer. MATERIALS AND METHODS: Eleven patients with gastric outlet obstruction due to gastric cancer were admitted to our hospital between January 2015 and March 2017 and enrolled in this study. Each patient underwent dPTEG as soon as possible. After dPTEG tubes were placed, gastric decompression was started immediately and enteral nutrition was started within 1 d. Feeding and decompression through the double tubes were continued until the day before operation. Using data from these patients, we investigated the efficacy and safety of dPTEG. RESULTS: dPTEG was performed successfully in all patients and no critical adverse effects were observed. Eight of the 11 patients underwent radical or palliative resection. Decompression of the stomach was achieved and nutritional status was significantly improved after dPTEG in all patients. CONCLUSIONS: We conclude that dPTEG is a safe and effective management technique for patients with gastric outlet obstruction and gastric dilatation due to gastric cancer.

Glycogen synthase kinase-3ß activity plays a key role in the antitumor effect of nafamostat mesilate in pancreatic cancer cells.

Pancreatic cancer is often resistant to chemotherapy. We previously showed the efficacy of combination treatment using gemcitabine and nafamostat mesilate (FUT-175) for patients with unresectable pancreatic cancer. However, the mechanisms that affect the sensitivity of FUT-175 are not fully understood. The purpose of the present study was to clarify the mechanism of the sensitivity to FUT-175, with a focus on the activity of glycogen synthase kinase-3ß (GSK-3ß). In vitro, we assessed sensitivity to FUT-175 in human pancreatic cancer cell lines (PANC-1 and MIAPaCa-2) and difference of signaling in these cells by cell proliferation assay, Western blot analysis and microarray. Next, we assessed cell viability, apoptotic signal and nuclear factor-kappa B (NF-κB) activity in response to treatment with FUT-175 alone and in combination with GSK-3 inhibitor or protein phosphatase 2A (PP2A) by cell proliferation assay, Western blot analysis and enzyme-linked immunosorbent assay. Phosphorylated GSK-3ß level was significantly higher in MIAPaCa-2 (high sensitivity cell) than in PANC-1 (low sensitivity cell). Cell viability and NF-κB activity were significantly decreased by addition of GSK-3 inhibitor to FUT-175, and levels of cleaved caspase-8 were increased by inhibition of GSK-3. PP2A inhibitor increased the levels of phosphorylated GSK-3ß and sensitized both cell lines to FUT-175 as measured by cell viability and apoptotic signal. The results indicate that GSK-3ß activity plays a key role in the antitumor effect of FUT-175 in pancreatic cancer cells, and regulation of GSK-3ß by PP2A inhibition could be a novel therapeutic approach for pancreatic cancer.

Pomalidomide promotes chemosensitization of pancreatic cancer by inhibition of NF-κB.

INTRODUCTION: Nuclear factor κB (NF-κB) plays an important role in cancer progression and causes therapeutic resistance to chemotherapy. Pomalidomide, a third-generation immunomodulating drug derived from thalidomide, has been approved for uncontrolled multiple myeloma. We hypothesized that pomalidomide may inhibit the anticancer agent-induced NF-κB activity and enhance chemosensitization of combination chemotherapy with gemcitabine and S1 (Gem/S1) in pancreatic cancer. METHODS: In vitro, we assessed NF-κB activity, induction of caspase cascade, cell apoptosis and cell proliferation using human pancreatic cancer cell lines (MIA PaCa-2 and PANC-1). In vivo, we established an orthotopic xenograft mouse model for human pancreatic cancer by injection of PANC-1 cells. At 5 weeks after injection, the animals were randomly divided into four groups and treated with Gem (100 mg/kg) /S1 (10 mg/kg), with oral administration of pomalidomide (0.5 mg/kg), with combination of gemcitabine, S1, and pomalidomide or vehicle only. RESULTS: Although chemotherapeutic agents induced NF-κB activation in pancreatic cancer cells, pomalidomide inhibited anticancer agent-induced NF-κB activation (p < 0.01). Of the four groups tested for the apoptosis-related caspase signals and apoptosis under both in vitro and in vivo conditions, Gem/S1/Pomalidomide group demonstrated the strongest activation of the caspase signals and proapoptotic effect. In Gem/S1/Pomalidomide group, cell proliferation and tumor growth were slower than those in other groups both in vitro and in vivo (p < 0.01). There were no obvious adverse effects except for thrombocytosis by using pomalidomide. CONCLUSIONS: Pomalidomide promotes chemosensitization of pancreatic cancer by inhibiting chemotherapeutic agents-induced NF-κB activation.

Optimal timing of preoperative indocyanine green administration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT® Endoscopic Fluorescence Imaging System.

INTRODUCTION: The PINPOINT® Endoscopic Fluorescence Imaging System (Novadaq, Mississauga, Canada) allows surgeons to visualize the bile ducts during laparoscopic cholecystectomy. Surgeons can continue operation while confirming the bile ducts' fluorescence with a bright-field/color image. However, strong fluorescence of the liver can interfere with the surgery. Here, we investigated the optimal timing of indocyanine green administration to allow fluorescent cholangiography to be performed without interference from the liver fluorescence. METHODS: A total of 72 patients who underwent laparoscopic cholecystectomy were included in this study. The timing of indocyanine green administration was set immediately before surgery and at 3, 6, 9, 12, 15, 18, and 24 h before surgery. The luminance intensity ratios of gallbladder/liver, cystic duct/liver, and common bile duct/liver were measured using the ImageJ software (National Institutes of Health, Bethesda, USA). Visibility of the gallbladder and bile ducts was classified into three categories (grades A, B, and C) based on the degree of visibility in contrast to the liver. RESULTS: The luminance intensity ratio for the gallbladder/liver, cystic duct/liver, and common bile duct/liver was ≥1 in the 15-, 18-, and 24-h groups. The proportion of cases in which evaluators classified the visibility of the gallbladder and bile ducts as grade A (best visibility) reached a peak in the 15-h group and decreased thereafter. CONCLUSIONS: In the present study, the optimal timing of indocyanine green administration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT Endoscopic Fluorescence Imaging System was 15 h before surgery.

New treatment strategy with nuclear factor-κB inhibitor for pancreatic cancer.

BACKGROUND: Because of difficulties with early diagnosis, most patients with pancreatic cancer receive chemotherapy. The National Comprehensive Cancer Network guidelines (version 2.2015) suggest therapy with gemcitabine (GEM) plus nab-paclitaxel (nPTX) as a category 1 recommendation for metastatic pancreatic ductal adenocarcinoma. According to the results of many studies, the activation of chemotherapeutic agents-induced nuclear factor-κB (NF-κB) causes chemoresistance. Hence, we hypothesized that the addition of nafamostat mesilate (NM), a potent NF-κB inhibitor, to GEM/nPTX therapy could enhance the antitumor effect in the treatment of pancreatic ductal adenocarcinoma. MATERIALS AND METHODS: In vitro, we assessed NF-κB activity and apoptosis under treatment with NM alone (80 µg/mL), with GEM/nPTX, or with a combination of NM and GEM/nPTX in human pancreatic cancer cell lines (PANC-1, MIA PaCa-2, and AsPC-1). In vivo, orthotopic pancreatic cancer mice (BALBc nu/nu) were divided into four groups: control (n = 13), NM (n = 13), GEM/nPTX (n = 13), and triple combination (n = 13). NM (30 mg/kg) was delivered intraperitoneally three times a week, and GEM/nPTX was injected intravenously once a week to orthotopic pancreatic cancer model mice. In the triple combination group, mice received NM followed by GEM/nPTX on the first day to avoid GEM/nPTX-induced NF-κB activation. RESULTS: In vitro and in vivo, NM inhibited GEM/nPTX-induced NF-κB activation, and a synergistic effect of apoptosis was observed in the triple combination group. Furthermore, tumor growth was significantly suppressed in the triple combination group compared with the other groups. CONCLUSIONS: NM enhances the antitumor effect of GEM/nPTX chemotherapy for orthotopic pancreatic cancer by inhibition of NF-κB activation.

The Decline of Amylase Level of Pancreatic Juice After Pancreaticoduodenectomy Predicts Postoperative Pancreatic Fistula.

OBJECTIVES: Postoperative pancreatic fistula (POPF) is a life-threatening complication after pancreaticoduodenectomy (PD). The aim of this study is to evaluate the significance of pancreatic amylase level of pancreatic juice for PF after PD. METHODS: The subjects were 46 patients who underwent PD between January 2012 and August 2015 at Jikei University Hospital. We retrospectively investigated the relation between patient characteristics including pancreatic amylase level of pancreatic juice through the pancreatic drainage tube and the incidence of POPF (grade B or grade C according to the International Study Group on the Pancreatic Fistula) using univariate and multivariate analyses. The decline of pancreatic amylase level of pancreatic juice was evaluated by 1 - postoperative day 3/postoperative day 1 ratio. RESULTS: In univariate analysis, nonductal adenocarcinoma (P = 0.0252), soft pancreatic remnant (P = 0.0155), and decline of pancreatic amylase level of pancreatic juice ≥ 80% (P = 0.0010) were significant predictors of POPF. In multivariate analysis, decline of pancreatic amylase level of pancreatic juice of 80% or greater (P = 0.0192) was the only significant independent parameter. CONCLUSIONS: Decline of pancreatic amylase level of pancreatic juice can predict POPF after PD.

Inhibitory Effect of Anti-rheumatic Drug Iguratimod for Hepatocellular Carcinogenesis by Inhibition of Serum Interleukin-8 Production.

BACKGROUND/AIM: Angiogenesis is a known factor for the development of hepatocellular carcinoma (HCC). The aim of this study was to assess the property of iguratimod, that is an anti-inflammatory drug for rheumatoid arthritis, on anti-angiogenesis and anti-carcinogensis for HCC. MATERIALS AND METHODS: In vitro, human umbilical vein endothelial cells were cultured under interleukin-8 (IL-8) with or without iguratimod. In vivo, a rat model with HCC received iguratimod or distilled water for 6 weeks. Diameter of the largest tumor, number of tumors and serum interleukin-8 concentration were compared between iguratimod and control groups. RESULTS: By an in vitro angiogenesis assay, it was found angiogenesis in iguratimod group was significantly lower than that in control group (p=0.013). In vivo, largest tumor diameter (p=0.036), number of the tumor (p=0.011) and serum interleukin-8 concentration (p=0.036) in the iguratimod group were significantly smaller and lower than those in the control group. CONCLUSION: Iguratimod may inhibit hepatocellular carcinogensis by inhibition of interleukin-8 production in a rat model.

The C-reactive Protein to Albumin Ratio Predicts Long-Term Outcomes in Patients with Pancreatic Cancer After Pancreatic Resection.

BACKGROUND: The C-reactive protein to albumin (CRP/Alb) ratio, a novel inflammation-based prognostic score, is associated with outcomes in septic patients. The prognostic value of CRP/Alb ratio has not been established in cancer patients. The aim of this study is to evaluate the significance of CRP/Alb ratio in therapeutic outcome after pancreatic resection for pancreatic cancer. METHODS: The study comprised 113 patients who had undergone pancreatic resection for pancreatic cancer between April 2001 and December 2011. We retrospectively investigated the relation between CRP/Alb ratio and disease-free as well as overall survival. RESULTS: The optimal cut-off level of the CRP/Alb ratio was 0.03. For disease-free survival, preoperative biliary drainage (p = 0.011), advanced tumor-node-metastasis (TNM) classification (p = 0.002), and higher CRP/Alb ratio (p = 0.049) by univariate analysis, and advanced TNM classification (p = 0.003) by multivariate analysis, were independent and significant predictors of cancer recurrence. For overall survival, preoperative biliary drainage (p = 0.012), advanced TNM classification (p = 0.001), and higher CRP/Alb ratio (p = 0.023) by univariate analysis, and advanced TNM classification (p = 0.003) and higher CRP/Alb ratio (p = 0.035) by multivariate analysis, were independent and significant predictors of poor patient outcome. CONCLUSIONS: The CRP/Alb ratio may be an independent and significant indicator of poor long-term outcomes in patients with pancreatic cancer after pancreatic resection.

Neutrophil to Lymphocyte Ratio Predicts Therapeutic Outcome After Pancreaticoduodenectomy for Carcinoma of the Ampulla of Vater.

BACKGROUND: Preoperative systemic inflammatory response is associated with a poor long-term prognosis after resection of malignant tumors. Several indicators of systemic inflammation have been reported to be predictive of outcomes, but have not been fully investigated. The aim of the present study was to evaluate the significance of the preoperative neutrophil to lymphocyte ratio (NLR) in therapeutic outcomes after pancreaticoduodenectomy for carcinoma of the ampulla of Vater. PATIENTS AND METHODS: The study comprised of 37 patients who had undergone pancreaticoduodenectomy for carcinoma of the ampulla of Vater between January 2000 and December 2011. We retrospectively investigated the relation between preoperative NLR and disease-free as well as overall survival. RESULTS: In multivariate analysis, preoperative biliary drainage (p=0.044) and pN2 or pN3 (p=0.027) status were independent and significant predictors of cancer recurrence, while significant predictors of overall survival consisted of pN2 or pN3 (p=0.025) and NLR ≥3 (p=0.026). CONCLUSION: Preoperative NLR is an independent and significant indicator of long-term outcome in patients with carcinoma of the ampulla of Vater after pancreaticoduodenectomy. Measurement of NLR may help decision making in the postoperative management of patients with carcinoma of the ampulla of Vater.

Dual inhibition of nuclear factor kappa-B and Mdm2 enhance the antitumor effect of radiation therapy for pancreatic cancer.

INTRODUCTION: Radiation therapy, alone or in combination with chemotherapy, is effective for patients with locally advanced and recurrent pancreatic cancer. Ionizing radiation induces cell cycle arrest and cell apoptosis through enhancement several signals such as p53, p21(Waf1/Cip1), and caspase. However, the therapeutic efficacy is attenuated by radiation-induced activation of NF-κB. Nafamostat mesilate, a synthetic serine protease inhibitor, inhibits NF-κB activation in pancreatic cancer. Therefore, we hypothesized that nafamostat mesilate inhibited radiation-induced activation of NF-κB and improves therapeutic outcome. RESULTS: In combination group, NF-κB activation was significantly inhibited in comparison with that of radiation group. Nafamostat mesilate obviously down-regulated the expression levels of Mdm2 compared with control cells or irradiated cells. Consequently, p53 expression was stabilized inversely in correlation with Mdm2 protein expression level. The expression levels of p53, p21(Waf1/Cip1), cleaved caspase-3 and -8 were the highest in the combination group. Nafamostat mesilate enhanced ionizing radiation-induced cell apoptosis and G2/M cell cycle arrest. In combination group, cell proliferation and tumor growth were significantly slower than those in other groups. CONCLUSION: Combination therapy of radiation with nafamostat mesilate exerts enhanced anti-tumor effect against human pancreatic cancer.

Preoperative Change in Peripheral Blood Monocyte Count May Predict Long-term Outcomes After Pancreaticoduodenectomy for Bile Duct Cancer.

BACKGROUND/AIM: The perioperative immunological response predicts long-term outcomes after resection for malignant tumors. The aim of the study was to evaluate the significance of perioperative change in the peripheral blood monocyte count regarding therapeutic outcome after pancreaticoduodenectomy for bile duct cancer. PATIENTS AND METHODS: The study comprised of 51 patients who had undergone pancreaticoduodenectomy for bile duct cancer between January 2000 and December 2012. We retrospectively investigated the relation between perioperative change in peripheral blood monocyte count and disease-free as well as overall survival. RESULTS: In multivariate analysis, advanced TNM stage, and decrease in monocyte count on postoperative day 1 in comparison with those before surgery were independent and significant predictors of poor disease-free survival and overall survival (p=0.014 and 0.004, and 0.010 and 0.006, respectively). CONCLUSION: Perioperative change in peripheral blood monocyte count is an independent and significant indicator of therapeutic outcome after pancreaticoduodenectomy in patients with bile duct cancer.

Negative Impact of Preoperative Endoscopic Biliary Drainage on Prognosis of Pancreatic Ductal Adenocarcinoma After Pancreaticoduodenectomy.

BACKGROUND/AIM: Patients with obstructive jaundice due to cancer of the pancreatic head often undergo preoperative endoscopic biliary drainage (EBD). The aim of the study was to evaluate the long-term impact of preoperative EBD following pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma. PATIENTS AND METHODS: We studied 106 patients who underwent PD for pancreatic ductal adenocarcinoma between May 2000 and November 2013 at the Jikei University Hospital. We retrospectively examined perioperative findings as predictors of prognosis and the relationship between preoperative EBD and recurrence rate as well as overall survival. RESULTS: In univariate analysis, significant factors associated with poor disease-free survival consisted of the presence of EBD (p=0.0213), poor tumor differentiation (p=0.0023) and tumor-node-metastasis (TNM) classification IV (p=0.0027), while significant factors associated with poor overall survival consisted of the presence of EBD (p=0.0047), poor tumor differentiation (p<0.0001), TNM classification IV (p=0.0031) and microscopic or macroscopic residual tumor (p=0.0184). In multivariate analysis, poor tumor differentiation (p=0.0033) and TNM classification IV (p=0.0020) were independent factors for poor disease-free survival, while the presence of EBD (p=0.0435), poor tumor differentiation (p=0.0009), TNM classification IV (p=0.0447) and microscopic or macroscopic residual tumor (p=0.0184) were independent factors for poor overall survival. CONCLUSION: Preoperative EBD may have a negative impact on prognosis after PD for pancreatic ductal adenocarcinoma.

Efficacy of a half-grip technique using a fine tip LigaSure™, Dolphin Tip Sealer/Divider, on liver dissection in swine model.

BACKGROUND: Recently, a lot of energy devices in the surgical field, especially in the liver surgery, have been developed, and a fine tip LigaSure™, Dolphin Tip Sealer/Divider (DT-SD) also has been used frequently to dissect liver parenchyma as well as ultrasonically activated device (USAD). However, the utility of this instrument for liver dissection (LD) is still unknown. Moreover, to reduce bleeding during LD, a half-grip technique (HGT) was contrived. We herein report an experimental study in swine model to evaluate the feasibility and effectiveness of HGT using DT-SD for LD. METHODS: The swine model experiment was carried out under general anesthesia by veterinarians. LD was performed repeatedly by DT-SD with the HGT (Group A, n = 6), or the conventional clamp-crush technique (CCT) (Group B, n = 6), and by variable mode USAD (Group C, n = 6). The dissection length and depth (cm) as well as bleeding volume (g) were measured carefully, and the dissection area (cm(2)) and speed (cm(2)/min) were calculated precisely. Histological examinations of the dissection surfaces were also executed. Mann-Whitney's U test was used for Statistical analyses with variance at a significance level of 0.05. RESULTS: Among the three groups, the three averages of dissection lengths were unexpectedly equalized to 8.3 cm. The dissection area (cm(2)) was 9.9 ± 5.1 in Group A, 9.8 ± 4.7 in Group B, and 9.9 ± 4.5 in Group C. The mean blood loss during LD was 10.6 ± 14.8 g in Group A, 41.4 ± 39.2 g in Group B, and 34.3 ± 39.2 g in Group C. For Group A, the bleeding rate was the least, 0.9 ± 1.0 g/cm(2), and the average depth of coagulation was the thickest, 1.47 ± 0.29 mm, among the three groups (p < 0.05). The dissection speed in Group A (1.3 ± 0.3 cm(2)/min) was slower, than that in Group C (p < 0.05). CONCLUSIONS: This report indicates firstly that the HGT using DT-SD bring the least blood loss when compared with CCT or USAD. Although the HGT is feasible and useful for LD, to popularize the HGT, further clinical studies will be needed.