Clinical features of extrahepatic portal vein obstruction: Myeloproliferative neoplasms eliminate hypersplenic hematologic changes in extrahepatic portal vein obstruction.

Extrahepatic portal vein obstruction (EHPVO) is a rare disease. Most EHPVO patients are usually referred to a gastroenterologist for intestinal bleeding and hypersplenic thrombocytopenia; however, hypercoagulative diseases may be occult in these patients and require anticoagulation. The purpose of this study was to elucidate the clinical characteristics of EHPVO. We conducted a retrospective analysis of the hospital database, evaluating the medical records of 15 patients (7 males, 8 females, mean age of onset 42.0 years, range 5-74 years). Thirteen of 15 EHPVO patients (86.7%) had intestinal varices. These included 10 esophageal (66.7%), 12 gastric (80.0%), and 6 ectopic varices (40.0%). Nine (60.0%) of 15 had a history of intestinal bleeding. Regarding comorbidities, 5 of 15 (33.3%) suffered from vascular diseases, including acute myocardial infarction, cerebral infarction, pulmonary embolism, Budd-Chiari syndrome, and mesenteric vein thrombosis. The former 3 vascular commodities manifested at less than 32 years of age. Four patients (26.7%) with JAK2V617F mutation were diagnosed as myeloproliferative neoplasm (MPN). 72.3% of EHPVO patients without MPN experienced thrombocytopenic state. No EHPVO patients with MPN experienced thrombo-leukocytopenia. The elevation of white blood cell and platelet counts, and decrease of protein S were seen in EHPVO with MPN, compared with EHPVO without MPN. EHPVO is frequently associated with underlying hypercoagulative factors, causing a dilemma between thrombotic complications and portal hypertensive bleeding. Most EHPVO patients experience an evident thrombocytopenic state due to severe hypersplenism; however, hypersplenic hematologic changes are eliminated in EHPVO with MPN. MPN should be suspected in EHPVO patients negative for thrombo-leukocytopenia.

Safety and Feasibility of Laparoscopic Liver Resection with the Clamp-Crush Method Using the BiSect.

BACKGROUND: Various energy devices are available for resection of the liver parenchyma during laparoscopic liver resection (LLR). We have historically performed liver resections using the Cavitron Ultrasonic Surgical Aspirator (CUSA). More recently, we have used new bipolar forceps (BiSect; Erbe Elektromedizin GmbH, Tübingen, Germany) to perform clamp-crush dissection with good results. The BiSect is a reusable bipolar forceps with a laparoscopic dissecting forceps tip and both an incision mode and coagulation mode. We evaluated the perioperative clinical course of patients who underwent LLR using the clamp-crush method with the BiSect compared with the CUSA. METHODS: This single-center case control study involved patients with liver metastasis from colorectal cancer who underwent LLR using either the BiSect or CUSA at our hospital from January 2019 to December 2022. We performed the LLR using CUSA from January 2019 to early October 2020. After introduction of the BiSect in late October 2020, we used BiSect for the LLR. Before surgery, the three-dimensional liver was constructed based on computed tomography images, and a preoperative simulation was performed. We evaluated the results of LLR using the BiSect versus the CUSA and assessed the short-term results of LLR. RESULTS: During the study period, we performed partial liver resection using the BiSect in 26 patients and the CUSA in 16 patients. In the BiSect group, the median bleeding volume was 55 mL, the median operation time was 227 minutes, and the median postoperative length of hospital stay was 9 days. In the CUSA group, the median bleeding volume was 87 mL, the median operation time was 305 minutes, and the median postoperative length of hospital stay was 10 days. There were no statistically significant differences in the clinical course including bile leakage, bile duct stenosis, and post operative hospital stay between the two groups. CONCLUSIONS: Compared with LLR using the CUSA, the clamp-crush method using the BiSect in LLR is a safe and useful liver transection technique. Further study should be conducted to clarify whether BiSect is safe and useful in LLR for patients with other tumor types and patients who undergo other procedures.

Distribution of Splenic Arterial Flow and Segmental Spleen Volume for Partial Splenic Arterial Embolization.

INTRODUCTION: The spleen is a lymphatic organ that manages immune surveillance of the blood, produces blood cells, and helps filter the blood, remove old blood cells, and fight infection. The normal splenic weight is approximately 65-265 g. This study evaluated spleen volume and segmental volume. METHODS: 121 patients who underwent enhanced CT at our center were analyzed. The spleen was divided into upper, middle, and lower segments according to arterial flow area, and the volume of each segment was measured. Patients were classified into two groups as those with and without liver cirrhosis, and differences in the distribution of the segments in these groups was evaluated. RESULTS: The mean upper, middle, and lower spleen segmental volume ratios were 35.4%, 37.0%, and 27.6%, respectively. In the liver cirrhosis group, the segmental splenic volume ratios for the upper, middle, and lower segments were 34.5%, 38.5%, and 28.0%, respectively, indicating that these ratios remain similar regardless of liver cirrhosis status. CONCLUSION: The present findings on segmental spleen volume are useful for estimating infarction volume in cases of partial splenic arterial embolization.

Apolipoprotein A2 isoforms associated with exocrine pancreatic insufficiency in early chronic pancreatitis.

BACKGROUND AND AIM: Apolipoprotein A2 (apoA2) isoforms have been reported to undergo the aberrant processing in pancreatic cancer and pancreatic risk populations compared with that in healthy subjects. This study aimed to clarify whether apoA2 isoforms were as useful as N-benzoyl-p-aminobenzoic acid (BT-PABA) test for exocrine pancreatic dysfunction markers in patients with early chronic pancreatitis (ECP). METHODS: Fifty consecutive patients with functional dyspepsia with pancreatic enzyme abnormalities (FD-P) (n = 18), with ECP (n = 20), and asymptomatic patients with pancreatic enzyme abnormalities (AP-P) (n = 12) based on the Rome IV classification and the Japan Pancreatic Association were enrolled in this study. The enrolled patients were evaluated using endoscopic ultrasonography and endoscopic ultrasonography elastography. Five pancreatic enzymes were estimated. Pancreatic exocrine function was analyzed using the BT-PABA test. Lighter and heavier apoA2 isoforms, AT and ATQ levels were measured by enzyme-linked immunosorbent assay methods. RESULTS: There were no significant differences in clinical characteristics such as age, gender, body mass index, alcohol consumption and smoking among patients with AP-P, FD-P, and ECP. The BT-PABA test and lighter apoA2 isoform, AT level in the enrolled patients had a significant correlation (P < 0.01). The BT-PABA test in patients with ECP was significantly lower (P = 0.04) than that in AP-P. ApoA2-AT level in patients with ECP was lower than that in AP-P, albeit, insignificantly. Interestingly, apo A2-AT level was significantly (P = 0.041) associated with exocrine pancreatic insufficiency by multiple logistic regression analysis. CONCLUSIONS: ApoA2-AT level is a useful tool to evaluate exocrine pancreatic insufficiency in the early stage of chronic pancreatitis.

Retroperitoneal solitary neurofibroma mimicking lymph node metastasis of colon cancer: a case report.

BACKGROUND: A neurofibroma is a benign tumor that arises from Schwann cells and neurofibromas occur throughout the skin of neurofibromatosis type 1 (NF-1: Von Recklinghausen's disease) patients. A retroperitoneal solitary neurofibroma without any clinical signs of NF1 has been rarely reported. Herein, we present a case of a retroperitoneal solitary neurofibroma mimicking lymph node metastasis of colon cancer as well as a literature review. CASE PRESENTATION: An 80-year-old woman with abdominal pain and nausea was transported and diagnosed with bowel obstruction arising from sigmoid colon cancer A colonic stent was inserted to alleviate the bowel obstruction. A computed tomography scan with contrast revealed a liver tumor in segment 3, and an enlarged lymph node around the abdominal aorta. Whole-body 18F-fluorodeoxyglucose-positron emission tomography-CT (FDG-PET-CT) examine revealed increased FDG uptake in the liver tumor and enlarged lymph node. Liver and distant lymph node metastasis were diagnosed and we made a plan for a two-stage operation of the colon cancer and the metastatic lesions because laparotomy resection was needed for the retroperitoneal lymph node. Laparoscopic sigmoid colectomy was performed first. Pathological examination showed a tubular adenocarcinoma. A laparotomy for the metastatic lesions was performed to ensure complete lymph node dissection secondly. Histopathological findings of the liver tumor showed metastasis of sigmoid colon cancer. However, the tissue regarded as the enlarged lymph node was diagnosed as a neurofibroma. No metastasis and recurrence were observed. CONCLUSION: Although most neurofibromas are benign, malignant transformation of a neurofibroma is possible. PET-CT showed our patient had a high accumulated retroperitoneal tumor co-existing with colon cancer and liver metastasis. The treatment strategy of a solitary neurofibroma must be selected carefully considering the site of occurrence and the patient's background and aggressive resection of a tumor co-existing with another malignant tumor is needed.

The T-CEA score: a useful prognostic indicator based on postoperative CEA and pathological T4 levels for patients with stage II-III colorectal cancer.

PURPOSE: To investigate a prognostic score for stage II-III colorectal cancer (CRC) based on post-CEA and pT4 levels. METHODS: Two cohorts of stage II-III CRC patients who underwent curative surgery between 2011 and 2017 were included. The prognostic score (T-CEA score) was calculated as follows: T-CEA-0, post-CEA ≤ 5 ng/mL and pT1-3; T-CEA-1, post-CEA > 5 ng/mL or pT4; T-CEA-2, post-CEA > 5 ng/mL and pT4. RESULTS: The T-CEA scores of the 587 patients were as follows: T-CEA-0 (n = 436; 74%), T-CEA-1 (n = 129; 22%), and T-CEA-2 (n = 10; 2%). The 5-year recurrence-free survival (RFS) rates of the T-CEA-0, 1, and 2 groups were 80.3%, 54.8%, and 0%, respectively (P < 0.01), and the 5-year overall survival (OS) rates were 90.9%, 74.2%, and 0%, respectively (T-CEA-0 vs T-CEA-1: P < 0.01, T-CEA-1 vs T-CEA-2: P = 0.04). Multivariate analysis revealed that an elevated T-CEA score of 1 or 2 was a significant risk factor for poor RFS (HR: 2.89, P < 0.01) and OS (HR: 2.85, P < 0.01). CONCLUSION: The T-CEA score is a reliable and convenient prognostic score for stage II-III CRC.

Reemployment and Recovery from Stigma after Metabolic/Bariatric Surgery: A Case Report and Review.

Bariatric surgery is performed worldwide to address morbid obesity. The benefits of this surgery are weight loss and a decrease in obesity-related complications. The relationship between metabolic/bariatric surgery and reemployment has been evaluated in Western countries, but few such studies have been performed in Japan because the number of metabolic/bariatric surgeries is small. Only a limited number of Japanese studies have evaluated the effects of bariatric surgery on obesity stigma, which affects employment and advancement opportunities for obese persons and may result in dismissal. We describe a case of bariatric surgery for a 39-year-old man who was dismissed from his job because of morbid obesity. Traditional weight loss methods failed to maintain weight loss and, preoperatively, the patient was receiving treatment for type 2 diabetes, hypertension, and abnormal lipid metabolism. He underwent sleeve gastrectomy and lost 50.4 kg (percent excess weight loss: 68.1%) in the first postoperative year. All medications were stopped after improvement in the results of laboratory blood tests and he was reemployed at 8 months after surgery. Increased social activity associated with employment is a factor in suppressing rebound weight gain after bariatric surgery, and weight loss associated with bariatric surgery helps decrease anti-obesity social stigma.

Laparoscopic Repair Using Self-Fixating Mesh in an Adult Patient with a Sciatic Hernia and Irreducible Small Bowel: A Case Report and Literature Review.

Sciatic hernia is a rare type of pelvic floor hernia. The herniated tissue can include the ureter, small and large bowel, and ovary, among other tissues. Only a few cases of laparoscopic treatment for a sciatic hernia with small-bowel incarceration have been reported. We report our experience using a laparoscopic approach for treatment of sciatic hernia in an 83-year-old woman and review the literature on sciatic hernias. The patient was referred to our hospital complaining of constipation and abdominal bloating. Computed tomography (CT) scanning showed a right sciatic hernia containing the small bowel. Laparoscopic repair of the sciatic hernia was performed using a self-fixating mesh. The patient was discharged after an uneventful postoperative course and has not developed abdominal bloating or constipation postoperatively. In conclusion, a sciatic hernia was successfully repaired using a laparoscopic trans-preperitoneal approach and ProGrip Self-Fixating Mesh.

Risk Factors for Esophagojejunal Anastomotic Leakage in Gastric Cancer Patients after Total Gastrectomy.

BACKGROUND: Leakage at the esophagojejunal anastomosis site is an important postoperative complication of total gastrectomy. We analyzed our surgical cases to determine the risk factors for esophagojejunal anastomotic leakage. METHODS: This study included 309 patients who underwent total gastrectomy and esophagojejunal anastomosis. The onset of esophagojejunal anastomotic leakage according to age, gender, performance status, American Society of Anesthesiologists classification, body mass index, presence or absence of diabetes, invasion depth, lymph node metastasis, histological type, presence or absence of esophageal infiltration, operative duration, amount of blood loss, experience of blood transfusion, procedural approach, and the prognostic nutritional index was analyzed. RESULTS: Univariate analyses revealed a significant difference in the rate of esophagojejunal anastomotic leakage due to advanced age, male gender, the presence of diabetes, the presence of esophageal infiltration, and blood loss ≥1,100 g. In the multivariate analysis, which included factors identified in the univariate analyses, advanced age, male gender, the presence of diabetes, and blood loss ≥1,100 g were identified as independent risk factors for esophagojejunal anastomotic leakage. CONCLUSIONS: Advanced age (≥68 years), male gender, diabetes, and massive blood loss are risk factors for esophagojejunal anastomotic leakage.

Clinical outcomes of antithrombin III-based therapy for patients with portal vein thrombosis: A retrospective, multicenter study.

AIM: The association between thrombolytic therapy and the outcome in patients with portal vein thrombosis (PVT) remains controversial. This study aimed to evaluate the outcome in patients with PVT who received antithrombin III-based therapy. METHODS: This study was a retrospective, multicenter study to investigate the liver-related events and the survival rates in 240 patients with PVT who received the therapy. RESULTS: The patients comprised 151 men and 89 women, with a median age of 69 years. The rate of favorable response, defined as maximum area of PVT changed to ≤75%, was 67.5% (162/240). The cumulative rates of liver-related events at 1, 2, and 3 years were 38.2%, 53.9%, and 68.5%, respectively. The multivariate analysis showed that viable hepatocellular carcinoma, absence of maintenance therapy, non-responder, and PVT progression were significantly associated with liver-related events. The PVT progression was observed in 23.3% (56/240). The multivariate analysis identified older age, absence of maintenance therapy, and non-responder as independent factors associated with PVT progression. The multivariate analysis revealed that younger age, no hepatocellular carcinoma, presence of maintenance therapy, and lower Model for End-stage Liver Disease-Sodium score significantly contributed to 3-year survival. Of the 240 patients, 13 (8.9%) prematurely discontinued treatment due to any adverse events. CONCLUSIONS: This study suggests that maintenance therapy, favorable response, and absence of PVT progression may suppress or control liver-related events in antithrombin III-based therapy for patients with PVT. Specifically, maintenance therapy could suppress not only liver-related events, but also PVT progression and improve the prognosis.

Two synchronous pseudoaneurysms after bile duct resection for distal cholangiocarcinoma.

Pseudoaneurysm is a potentially life-threatening complication after hepatobiliary pancreatic surgery. Although various measures have been taken to prevent the formation of postoperative pseudoaneurysms, completely avoiding complications can be difficult. An 83-year-old man underwent bile duct resection and systematic regional lymphadenectomies for distal cholangiocarcinoma. Polyethylene glycolic acid mesh with fibrin glue was applied to the pancreas around the distal stump and detached artery to prevent leakage of pancreatic juice and reinforce the arterial wall. Screening contrast-enhanced computed tomography on the 7th postoperative day indicated no pseudoaneurysm. The patient was discharged on the 20th postoperative day after an uneventful course. However, 4 days later, the patient visited the emergency outpatient department with a complaint of fever. Contrast-enhanced computed tomography revealed an abscess formation and a pseudoaneurysm around it. Emergency celiac arteriography revealed two pseudoaneurysms at the left hepatic artery and posterior superior pancreaticoduodenal artery; they were successfully treated with transcatheter arterial embolization using microcoils and covered stent placement. The patient was discharged 9 days after interventional radiology treatment. At the 14 months postoperative follow-up, the patient had no recurrence or stent obstruction. Multiple synchronous pseudoaneurysms are rare; accurately identifying the site by angiography and selecting appropriate treatment for each site is important.

The Prognostic Nutritional Index as a Predictor of Gastric Cancer Progression and Recurrence.

BACKGROUND: Gastric cancer can recur soon after treatment. We evaluated the prognostic nutritional index (PNI), a predictor of postoperative complications, and examined the association of PNI with progression and recurrence of gastric cancer. METHODS: We retrospectively investigated data from 697 patients who had undergone surgery for gastric carcinoma (excluding those with stage IV disease) and analyzed associations of age, sex, performance status (PS), American Society of Anesthesiologists (ASA) classification, diabetes, depth of main tumor (T), lymph node metastasis, postoperative complications, recurrence, and survival with PNI. We also performed multivariate analysis to identify factors associated with survival. RESULTS: PNI significantly decreased with age and was significantly lower in women. PNI was significantly positively correlated with PS. PNI was significantly lower for ≥T2 cancers and in patients with lymph node metastasis. There was no association between postoperative complications and PNI. PNI was significantly lower for patients who developed recurrence than for those who did not. The survival rate was examined for groups with a PNI of ≥45 (high PNI) and <45 (low PNI). Both 5-year overall survival (OS) and cancer-specific survival (CS) were significantly worse for the low PNI group. Multivariate analysis showed that PNI was an independent predictor of OS and CS. CONCLUSIONS: PNI was associated with progression and recurrence of gastric cancer.

Huge esophageal gastrointestinal stromal tumor successfully resected under mediastino-laparoscopic transhiatal esophagectomy: a case report.

BACKGROUND: Esophageal gastrointestinal stromal tumors (E-GISTs) are often diagnosed early due to complaints such as dysphagia and are rarely found to be huge in size. Here, we report the treatment of a case of huge E-GIST successfully resected by minimally invasive surgery after neoadjuvant imatinib therapy. CASE PRESENTATION: An 86-year-old male patient with a 3-month history of dysphagia was referred to our hospital because of a suspected mediastinal tumor on chest X-ray. The chest computed tomography scan revealed a huge solid tumor, of about 100 mm in diameter, protruding into the left thoracic cavity. Histopathological examination results of fine-needle aspiration biopsy under endoscopic ultrasonography revealed a c-kit and CD34-positive esophageal gastrointestinal stromal tumor. The patient received neoadjuvant therapy with imatinib (400 mg/day) to reduce the size of the tumor and prevent rupture during resection. After 28 days of oral administration of imatinib, the tumor size decreased. However, the patient refused to continue treatment with imatinib and therefore underwent mediastino-laparoscopic transhiatal esophagectomy. We successfully resected the tumor completely with mediastino-laparoscopic surgical techniques. Esophageal reconstruction was performed using a gastric tube in the posterior sternal route. After an uneventful postoperative course, the patient was discharged postoperative day 14. Immunohistochemical findings of the resected specimen showed that the tumor cells were positive for c-kit, DOG-1 and CD34 and negative for smooth muscle actin and S100. CONCLUSIONS: Hybrid surgical procedure utilizing mediastino-laparoscopy might be useful for high-risk patient with esophageal tumors.

Periappendiceal fluid collection on preoperative computed tomography can be an indication for interval appendectomy: a retrospective study.

BACKGROUND: The treatment strategies for acute appendicitis, such as emergency appendectomy (EA), interval appendectomy (IA), and repeating nonoperative management (NOM), are controversial. In this study, we examined the preoperative factors that can be used to distinguish which patients should undergo IA. METHODS: We retrospectively identified 902 patients who underwent surgery for appendicitis in our hospital from January 2010 to December 2021. Of these patients, 776 were included in this study. The patients were divided into two groups: those with a periappendiceal fluid collection (PAFC) on preoperative computed tomography (PAFC-positive group, n = 170) and those without a PAFC (PAFC-negative group, n = 606). In each group, we compared patients who underwent EA and IA. RESULTS: In the PAFC-positive group, patients who underwent EA had a significantly higher postoperative complication rate than those who underwent IA (40.5% vs. 24.0%, p = 0.037). In the multivariate analysis, only the presence of PAFC was significantly associated with an increased risk of postoperative complications (odds ratio, 7.11; 95% confidence interval, 2.73-18.60; p < 0.001). The presence of PAFC alone was not significantly associated with an increased risk of IA or NOM failure (odds ratio, 1.48; 95% confidence interval, 0.19-11.7; p = 0.71). The rate of neoplasia on pathologic examination was significantly higher in the PAFC-positive than PAFC-negative group (7.6% vs. 1.5%, p < 0.001); the rate of carcinoma was also higher in the PAFC-positive group (2.4% vs. 0.17%, p = 0.02). CONCLUSIONS: The presence of PAFC on preoperative computed tomography was found to be a risk factor for postoperative complications but not IA or NOM failure. It was also correlated with neoplasia as the etiology of appendicitis. Therefore, PAFC positivity is useful as an indication for IA.

Medical Treatment for Hepatocellular Carcinoma in Japan.

Liver cancer, including hepatocellular carcinoma (HCC), is the fifth most common cause of cancer deaths in Japan. The main treatment options for HCC are surgical resection, liver transplantation, radiofrequency ablation (RFA), transarterial chemoembolization (TACE), and systemic chemotherapy. Here, recent medical treatments for HCC, including surgery, percutaneous ablation, transcatheter arterial chemoembolization/transcatheter arterial embolization, and drug therapy, are reviewed with a focus on Japan.

Management of Simple Hepatic Cyst.

Simple hepatic cysts are typically saccular, thin-walled masses with fluid-filled epithelial lined cavities. They arise from aberrant bile duct cells that develop during embryonic development. With the development of diagnostic modalities such as ultrasonography (US), CT, and MRI, simple hepatic cysts are frequently detected in clinical examinations. US is the most useful and noninvasive tool for diagnosis of simple hepatic cysts and can usually differentiate simple hepatic cysts from abscesses, hemangiomas, and malignancies. Cysts with irregular walls, septations, calcifications, or daughter cysts on US should be evaluated with enhanced CT or MRI, to differentiate simple hepatic cysts from cystic neoplasms or hydatid cysts. Growth and compression of hepatic cysts cause abdominal discomfort, pain, distension, and dietary symptoms such as nausea, vomiting, a feeling of fullness, and early satiety. Complications of simple hepatic cysts include infection, spontaneous hemorrhage, rupture, and external compression of biliary tree or major vessels. Asymptomatic simple hepatic cysts do not require treatment. Treatment for symptomatic simple hepatic cysts includes percutaneous aspiration, aspiration followed by sclerotherapy, and surgery. The American College of Gastroenterology clinical guidelines recommend laparoscopic fenestration because of its high success rate and low invasiveness. Percutaneous procedures for treatment of simple hepatic cysts are particularly effective for immediate palliation of patient symptoms; however, they are not generally recommended because of the high rate of recurrence. Management of simple hepatic cysts requires correct differentiation from neoplasms and infections, and selection of a reliable treatment.

The Influences of Obesity in Laparoscopic and Open Distal Gastrectomy for Patients with Early Gastric Cancer.

BACKGROUND: A recent increase in the number of surgeries performed on obese patents has raised several issues. In this study, we examined the effects of obesity on laparoscopic and open distal gastrectomy. METHODS: A total of 262 patients with gastric cancer (cStage I) who underwent distal gastrectomy were classified into open distal gastrectomy (ODG) (145 patients) and laparoscopic distal gastrectomy (LDG) (117 patients) groups. According to their body mass index (BMI), they were subdivided into obese (BMI ≥ 25) and non-obese patients (BMI < 25) to examine the duration of surgery, blood loss, the number of lymph node dissections, postoperative hospital stay, and incidence of postoperative complications. RESULTS: The duration of surgery was longer and blood loss was higher for obese patients than for non-obese patients in both groups. The results for these two endpoints were significantly reduced in the LDG group than in the ODG group both in obese and non-obese patients. Furthermore, the number of lymph nodes dissected tended to be higher in the LDG group than in the ODG group in obese patients. Postoperative hospital stay was not significantly different between obese and non-obese patients in both groups, but was significantly shorter in the LDG group than in the ODG group regardless of the body weight. The incidence of postoperative complications was significantly higher in obese patients than in non-obese patients, although the difference between the groups was not significant. CONCLUSIONS: These findings indicate that LDG may be useful for obese patients with cStage I gastric cancer.

[The Short-Term and Long-Term Outcomes of Laparoscopic and Open Distal Gastrectomy].

We compared laparoscopic gastrectomy and open gastrectomy for the early gastric cancer. Laparoscopic surgery was comparable to laparotomy in terms of operation time and number of lymph node dissections, significantly less bleeding volume, postoperative hospital stay, and lower postoperative complication rate. As a result of E-PASS, surgical invasion was significantly low and the overall risk score was also significantly low. There was no difference in cancer-specific survival, and overall survival was significantly better with laparoscopic distal gastrectomy. Based on the above, laparoscopic gastrectomy is considered to be superior to open gastrectomy as a surgical technique for the early gastric cancer.

Management of portal hypertension based on portal hemodynamics.

Portal hypertension is most commonly caused by chronic liver disease. As liver damage progresses, portal pressure gradually elevates and hemodynamics of the portal system gradually change. In normal liver, venous returns from visceral organs join the portal trunk and flow into the liver (hepatopetal blood flow). As portal pressure increases due to liver damage, congestion of some veins of the visceral organ occurs (blood flow to and from). Finally, the direction of some veins (the left gastric vein in particular) of the visceral organ change (hepatofugal blood flow) and develop as collateral veins (portosystemic shunt) to reduce portal pressure. Therefore, esophagogastric varices serve as drainage veins for the portal venous system to reduce the portal pressure. In chronic liver disease, as intrahepatic vascular resistance is increased (backward flow theory) and collateral veins develop, adequate portal hypertension is required to maintain portal flow into the liver through an increase of blood flow into the portal venous system (forward flow theory). Splanchnic and systemic arterial vasodilatations increase the blood flow into the portal venous system (hyperdynamic state) and lead to portal hypertension and collateral formation. Hyperdynamic state, especially around the spleen, is detected in patients with portal hypertension. The spleen is a regulatory organ that maintains portal flow into the liver. In this review, surgical treatment, interventional radiology, endoscopic treatment, and pharmacotherapy for portal hypertension (esophagogastric varices in particular) are described based on the portal hemodynamics using schema.

Prediction of portal vein thrombosis after hepatectomy for hepatocellular carcinoma.

PURPOSE: Portal vein thrombosis (PVT) following hepatectomy is potentially life-threatening. We aimed to evaluate the incidence of PVT after hepatectomy for hepatocellular carcinoma and identify coagulation and fibrinolytic factors that could predict early-stage postoperative PVT. METHODS: A retrospective analysis was conducted on 65 hepatocellular carcinoma patients who underwent radical hepatectomy. The risk factors for postoperative PVT were identified based on univariate and multivariate analyses, and the levels of coagulation and fibrinolytic factors were measured during the perioperative period. RESULTS: The incidence of PVT after hepatectomy was 20.0%. The patients were divided into two groups: those with PVT (n=13; PVT group) and those without PVT (n=52; no-PVT group). The frequency of the use of the Pringle maneuver during surgery was higher in the PVT group than in the no-PVT group, and the postoperative/preoperative ratios of thrombin-antithrombin III complex (TAT) and of D-dimer were significantly higher in the PVT group. CONCLUSION: A high incidence of PVT was found in hepatocellular carcinoma patients after hepatectomy. The frequency of the Pringle maneuver is a potential risk factor for postoperative PVT, and the postoperative/preoperative TAT and D-dimer ratios may be used as early predictors of PVT after hepatectomy for hepatocellular carcinoma.