Effects of perioperative immunonutrition on cell-mediated immunity, T helper type 1 (Th1)/Th2 differentiation, and Th17 response after pancreaticoduodenectomy.

BACKGROUND: The mechanisms of immunonutrition on reducing infectious complications are still poorly understood. This prospective randomized study was designed to determine whether immunonutrition influences the following factors: cell-mediated immunity, differentiation of T helper type 1 (Th1) and Th2 cells, interleukin (IL)-17-producing CD4(+) helper T (Th17) cell response, and infectious complication rate after pancreaticoduodenectomy. METHODS: Thirty patients who underwent pancreaticoduodenectomy were divided into 3 groups. Ten patients in the perioperative group received immune-enhancing diets enriched with arginine, omega-3 fatty acids, and RNA for 5 days before operative resection, which was prolonged after operative resection by enteral infusion. Ten patients in the postoperative group received early postoperative enteral infusion of the same enriched formula with no artificial nutrition before operative resection. Ten patients in the control group received total parenteral nutrition postoperatively. The primary endpoint was immune responses; the secondary endpoint was the rate of infectious complications. RESULTS: Concanavalin A (Con A)- or phytohemagglutinin (PHA)-stimulated lymphocyte proliferation and natural killer cell activity were significantly higher in the perioperative group than in the other groups. Messenger RNA (mRNA) expression levels of T-bet, interferon-gamma (IFN-gamma), related orphan receptor gammat (RORgammat), and interleukin-17F (IL-17F) were significantly higher in the perioperative group than in the other groups. In the perioperative group, the rate of infectious complications was significantly reduced compared with that in the other groups. CONCLUSION: Perioperative immunonutrition reduced stress-induced immunosuppression after a major stressful operative resection. The modulation of Th1/Th2 differentiation and Th17 response may play important roles in this immunologic effect.

Effect of hyperbaric oxygen therapy on patients with adhesive intestinal obstruction associated with abdominal surgery who have failed to respond to more than 7 days of conservative treatment.

BACKGROUND/AIMS: To investigate the effects of hyperbaric oxygen (HBO) therapy on patients with adhesive intestinal obstruction who have failed to respond to more than 7 days of conservative treatment. METHODOLOGY: Six hundred eighty-five patients, who were admitted a total of 879 times for adhesive intestinal obstruction, were divided into groups according to the treatment and interval between the first day of the therapy and clinical symptoms of obstruction; tube decompression therapy within 7 days after appearance of clinical symptoms (Group I: n = 321), clinical symptoms that have persisted for less than 7 days before the start of HBO therapy (Group II: n = 498), and for more than 7 days (Group III: n = 60). RESULTS: The overall resolution and mortality rates in the cases of adhesive intestinal obstruction were 79.8% and 2.2% in Group I, 85.9% and 1.4% in Group II, and 81.7% and 1.6% in Group III, respectively. Group II had significantly better resolution rates than Group I (odds ratio 1.6, p < 0.02). CONCLUSIONS: HBO therapy may be useful in management of adhesive intestinal obstruction associated with abdominal surgery, even in patients who fail to respond to other conservative treatments. HBO therapy may be a preferred option for treatment of patients for whom surgery should be avoided.

Guidelines for chemotherapy of biliary tract and ampullary carcinomas.

Few randomized controlled trials (RCTs) with large numbers of patients have been conducted to date in patients with biliary tract cancer, and standard chemotherapy has not been established yet. In this article we review previous studies and clinical trials regarding chemotherapy for unresectable biliary tract cancer, and we present guidelines for the appropriate use of chemotherapy in patients with biliary tract cancer. According to an RCT comparing chemotherapy and best supportive care for these patients, survival was significantly longer and quality of life was significantly better in the chemotherapy group than in the control group. Thus, chemotherapy for patients with biliary tract cancer seems to be a significant treatment of choice. However, chemotherapy for patients with biliary tract cancer should be indicated for those with unresectable, locally advanced disease or distant metastasis, or for those with recurrence after resection. That is why making the diagnosis of unresectable disease should be done with greatest care. As a rule, pathological diagnosis, including cytology or histopathological diagnosis, is preferable. Chemotherapy is recommended in patients with a good general condition, because in patients with general deterioration, such as those with a performance status of 2 or 3 or those with insufficient biliary decompression, the benefit of chemotherapy is limited. As chemotherapy for unresectable biliary tract cancer, the use of gemcitabine or tegafur/gimeracil/oteracil potassium is recommended. As postoperative adjuvant chemotherapy, no effective adjuvant therapy has been established at the present time. It is recommended that further clinical trials, especially large multi-institutional RCTs (phase III studies) using novel agents such as gemcitabine should be performed as soon as possible in order to establish a standard treatment.

Hyperbaric oxygen therapy as a prophylactic and treatment against ileus and recurrent intestinal obstruction soon after surgery to relieve adhesive intestinal obstruction.

BACKGROUND AND AIM: Nonoperative management of cases of adhesive intestinal obstruction would be ideal, especially for patients who have recently undergone surgery to relieve the same condition. We aimed to examine whether hyperbaric oxygen (HBO) therapy might have therapeutic potential for the treatment of postoperative paralytic ileus and recurrent adhesive intestinal obstruction soon after surgery, to relieve adhesive intestinal obstruction, because of its unique mechanisms in these contexts. METHODS: A total of 133 patients were enrolled in the present study. We examined non-per os periods, hospital stay, and clinical course according to the postoperative course of the 133 patients. RESULTS: After surgical intervention, 75 patients left the hospital without morbidity. Nineteen patients were successfully administered prophylactic HBO therapy to facilitate intestinal motility and to prevent paralytic ileus. The remaining 39 patients suffered from postoperative paralytic ileus or early recurrence of obstruction during the same hospitalization period. The patients who underwent prophylactic HBO therapy had significantly shorter non-per os periods and hospital stays after surgery than those who were not initially given HBO therapy (P < 0.05). Similarly, there were significant differences in duration of hospital stay after surgery between patients with HBO therapy as treatment and those who received other conservative therapies (P < 0.05). CONCLUSIONS: HBO therapy may have a prophylactic effect on postoperative paralytic ileus and may be of therapeutic benefit in the management of early recurrent adhesive intestinal obstruction following surgery to relieve adhesive intestinal obstruction.

Hyperbaric oxygen therapy for the treatment of postoperative paralytic ileus and adhesive intestinal obstruction associated with abdominal surgery: experience with 626 patients.

BACKGROUND/AIMS: The results of hyperbaric oxygen (HBO) therapy for treatment of postoperative paralytic ileus and adhesive intestinal obstruction associated with abdominal surgery are unknown. METHODOLOGY: A retrospective review of postoperative paralytic ileus and adhesive intestinal obstruction associated with abdominal surgery in 626 patients required 758 admissions who underwent HBO therapy was undertaken to examine the efficacy of HBO therapy. RESULTS: The overall resolution rates for patients receiving HBO therapy in cases of postoperative paralytic ileus and adhesive intestinal obstruction were 92% and 85%, respectively. Among patients who were more than 75 years old, the therapies resolved 35 (97%) of 36 cases of postoperative paralytic ileus and 42 (81%) of 52 cases of adhesive intestinal obstruction, which was comparable to the results for patients less than 75 years old. The mortality rate was 1.2% overall. Complications related to HBO therapy occurred in 3.8% of the admissions, and most of them were not serious. CONCLUSIONS: These results suggest that HBO therapy might deserve further assessment for use in management of postoperative paralytic ileus and adhesive intestinal obstruction as a new modality. HBO therapy is safe and non-invasive, and may be useful in the elderly patients, since mortality was relatively low in this series.

[Surgical resection for pancreatic cancer combined with preoperative carbon-ion beam irradiation].

Prognosis of pancreatic cancer is still remarkably poor, even if complete resection was performed by enlarged abscission. On the other hand, carbon-ion beam therapy is giving good results in some selected carcinoma such as small cell lung cancer, prostate cancer, uterus cancer, and soft tissue/bone tumor. In this report, we discuss four patients with pancreatic cancer treated by surgical pancreatectomy combined with preoperative carbon-ion beam irradiation. All patients were irradiated with 48 GyE carbon-iron beam by HIMAC (Heavy Ion Medical Accelerator in Chiba) to the pancreatic area including lymph nodes and nerve plexus. Severe cholangitis, as the postoperative complication, had occurred in one of the patients. However, there was no complication or disorder caused by carbon-iron radiation. All four patients are alive now, but two of them developed tumor recurrence, one with hepatic metastasis and the other with peritoneal dissemination. Surgical treatment for pancreatic cancer combined with preoperative carbon-ion irradiation is expected as a promising cure, but it is necessary to examine more cases in the future to evaluate the clinical outcome of this treatment.