Operative timing of laparoscopic cholecystectomy for acute cholecystitis in a Japanese institute.

BACKGROUND AND OBJECTIVES: In patients with acute cholecystitis who cannot undergo early laparoscopic cholecystectomy (within 72 hours), 6 weeks to 12 weeks after onset is widely considered the optimal timing for delayed laparoscopic cholecystectomy. However, there has been no clear consensus about it. We aimed to determine optimal timing for delayed laparoscopic cholecystectomy for acute cholecystitis. METHODS: Medical records of 100 patients who underwent standard laparoscopic cholecystectomy were reviewed retrospectively. Patients were divided into group 1, patients undergoing laparoscopic cholecystectomy within 72 hours of onset; group 2, between 4 days to 14 days; group 3, between 3 weeks to 6 weeks; group 4, >6 weeks. RESULTS: No significant differences existed between groups in conversion rate to open surgery, operation time, blood loss, or postoperative morbidity, and hospital stay. However, total hospital stay in groups 1 and 2 was significantly shorter than that in groups 3 and 4 (P<.01). In addition, the total hospital stay in group 3 was also significantly shorter than that in group 4 (P<.01). CONCLUSIONS: Best timing of laparoscopic cholecystectomy for acute cholecystitis may be within 72 hours, and the delayed timing of laparoscopic cholecystectomy in patients who cannot undergo early laparoscopic cholecystectomy is probably as soon as possible after they can tolerate laparoscopic cholecystectomy.

Surgical outcomes of totally extraperitoneal repair for inguinal hernia: A retrospective multicenter propensity score-matched study.

BACKGROUND: Laparoscopic surgical approaches, including total extraperitoneal repair (TEP), have been widely accepted for inguinal hernia repair in Japan. However, there are limited data regarding recurrence after TEP in Japan, given the limited versatility of this procedure. This study retrospectively evaluated the rates of hernia recurrence after TEP and open mesh repair at multiple Japanese centers. METHODS: This retrospective study evaluated 1917 patients who underwent inguinal hernia repair at 32 institutions in the Oita prefecture between January 2014 and December 2015. Eligible patients were grouped according to whether they underwent TEP (1011 patients) or open mesh repair (636 patients). Propensity score matching was performed 1:1 (total: 1076 patients, 538 patients from each group). The outcomes of interest were recurrence, morbidity, and postoperative recovery. RESULTS: The TEP and open mesh repair groups had similar baseline characteristics. After propensity score matching, there was no significant difference between the two groups in terms of recurrence rate (TEP: 0.5% vs open mesh repair: 1.0%, P = .375). However, the TEP group had significantly longer operating times (median: 70.2 min vs 65.0 min, P < .001), significantly less blood loss (0-5.1 mL vs 0-20.4 mL, P < .001), and significantly shorter postoperative hospital stays (median: 5.0 days vs 6.4 days, P < .001). The overall incidences of morbidity were 6.2% in the TEP group and 7.2% in the open mesh repair group (P = .535). CONCLUSION: This multicenter retrospective study with propensity score matching revealed that the recurrence rates were similarly low for TEP and open mesh repair of inguinal hernia. Thus, a well-trained surgical team could use TEP as a standard procedure.

Laparoscopic splenectomy in patients with inflammatory pseudotumor of the spleen: Report of 2 cases and review of the literature.

We report 2 cases of splenic inflammatory pseudotumor treated by laparoscopic splenectomy. The first patient was a 58-year-old woman who complained of constipation. Computed tomography (CT) showed a well-demarcated mass that measured 4 cm in diameter and was not enhanced. She underwent laparoscopic splenectomy under a preoperative diagnosis of hemangioma. The final histopathologic diagnosis was inflammatory pseudotumor. The second patient was a 29-year-old man who complained of abdominal pain. Computed tomography revealed a demarcated splenic tumor that measured 3 cm in diameter and was not enhanced. Laparoscopic splenectomy was performed. The pathologic and operative diagnoses were both inflammatory pseudotumor. In both cases, the postoperative course was uneventful, and the postoperative hospital stays were 10 and 11 days. Preoperative diagnosis of a splenic inflammatory pseudotumor is very difficult. However, laparoscopic splenectomy is safe and beneficial treatment for this tumor and should be performed in cases in which it is diagnosed.

Pancreatic resection with ultrasonically activated scalpel: preliminary observations.

BACKGROUND/AIMS: Resection of the pancreas was performed with a surgical knife, electrocautery, or an automatic stapler. We histologically and radiologically evaluated the applicability of the ultrasonically activated scalpel (Coagulating Shears, CS, Ethicon Endo-Surgery, Cincinnati, OH, USA) for resecting pancreatic parenchyma and reported our clinical observations on the use of the coagulating shears. METHODOLOGY: Resection of the pancreas was performed with the coagulating shears in 8 patients and with electrocautery in 5. The pancreas was transected with blunt mode of the coagulating shears at output power level of 3. Histologic thermal degeneration of the surface was evaluated with hematoxylin-eosin and Azan-Mallory staining. Radiologic pancreaticography was carried out on 4 resected specimens. We report 8 practical applications of the coagulating shears and compared its use with that of electrocautery in pancreatic surgery. RESULTS: Histologically, a coagulum of degenerated tissue completely closed each end of the vessels in the transected surface of all cases. The mean breadth of thermal degeneration resulting from the use of the coagulating shears was significantly less than that caused by electrocautery (1.33 +/- 0.21 vs. 3.05 +/- 0.34 mm, respectively) Pancreaticograms showed the closed branches of the pancreatic duct, but the closed main pancreatic duct had burst in 1 of 4 cases. Clinically, pancreatic fistula occurred in 1 of 8 patients who underwent pancreatic surgery with the coagulating shears. CONCLUSIONS: Pancreatic resection with the coagulating shears might be effective and feasible as long as the main pancreatic duct is ligated.

Lymphatic spread differs according to tumor location in extrahepatic bile duct cancer.

BACKGROUND/AIMS: Identification of nodal involvement according to primary tumor location in extrahepatic bile duct carcinoma may guide surgical therapy. METHODOLOGY: Pathologic data of 81 patients who underwent curative operation for bile duct carcinoma were studied to clarify the differences in lymphatic spread from distal bile duct carcinoma, middle bile duct carcinoma, and proximal bile duct carcinoma. RESULTS: Lymph node metastases were present in 25 of 41 patients (61%) with distal bile duct carcinoma, 9 of 19 (47%) with middle bile duct carcinoma, and 11 of 21 (52%) with proximal bile duct carcinoma. The number of positive nodes per node-positive patient was greater in patients with middle bile duct carcinoma than in those with distal- or proximal bile duct carcinoma (mean 5.33 vs. 3.56 or 2.64, p < 0.05). Lymph nodes in the hepatoduodenal ligament were most frequently involved regardless of the primary tumor location. The frequency of distal- and middle bile duct carcinoma patients with metastasis to the superior mesenteric or para-aortic nodes was significantly higher than that of proximal bile duct carcinoma patients (p < 0.05 and p < 0.05). CONCLUSIONS: Patterns of lymphatic spread were different according to primary tumor location in bile duct carcinoma. Metastatic nodes were spread widely, from the hepatoduodenal ligament or posterior pancreaticoduodenal region to the nodes around the superior mesenteric artery and abdominal aorta, in distal- and middle bile duct carcinoma.

Staging with helical computed tomography and laparoscopy in pancreatic head cancer.

BACKGROUND/AIMS: Helical computed tomography provides valuable information about extent of pancreatic cancer. However, it remains difficult to detect small distant metastases. Laparoscopic examination is becoming standard for cancer staging. METHODOLOGY: Between 1995 and 1999, 45 patients with radiologically resectable pancreatic head cancer were analyzed retrospectively to clarify the indications for and role of staging laparoscopy. Computed tomography was examined for tumor size and spread to portal or superior mesenteric veins (PV) and celiac or superior mesenteric arteries (A). RESULTS: There were 29 (64%) patients with resectable disease, 4 (9%) with localized unresectable, and 12 (27%) with metastatic (hepatic in 7 and peritoneal in 5). Patients with metastatic disease were more likely to present with abdominal pain, vomiting, and back pain than were patients with resectable disease (p < 0.05). The mean tumor size and involvement of PV or A were greater in metastatic patients than in resectable patients (p < 0.005 or p < 0.01). The survival rate for patients with metastatic disease was lower than that for patients with resectable disease (p < 0.0001). CONCLUSIONS: According to clinical features and computed tomography findings, laparoscopic exploration is recommended for cancer staging. Helical computed tomography and staging laparoscopy categorize patients into those with localized and those with metastatic disease which considerably correlated with survivals.

Clinical significance of combined pancreas and portal vein resection in surgery for pancreatic adenocarcinoma.

BACKGROUND/AIMS: Surgical resection remains the only potentially curative treatment for pancreatic adenocarcinoma for which the resectability and prognosis are still poor. The aim of the present study was to evaluate the efficacy of portal vein resection for pancreatic adenocarcinoma. METHODOLOGY: Between August 1983 and December 2000, 69 patients with pancreatic ductal cell carcinoma underwent resection in our department; 22 of the 69 had combined resection of the pancreas and portal vein. When the pancreas could not be separated from the portal vein, the vein was judged to be invaded by cancer and resected. RESULTS: The mortality rate for portal vein resection was 4.5%, which was similar to that in 47 patients with no resection of the portal vein (2.1%). Postoperative histologic analysis showed that 8 (37%) of the patients who underwent portal vein resection did not have cancer invasion to the portal vein, and 3 of them remain disease free to date. The 3-year survival rate of patients undergoing portal vein resection was 21.3%, and that of patients without portal vein resection was 20.0%. CONCLUSIONS: Resection of the portal vein in cases of pancreatic ductal cell carcinoma has no adverse affect on long-term survival for selected patients.

[A case of advanced gastric cancer responding to combination chemotherapy with low-dose 5-FU plus CDDP].

A 56-year-old man presented with dysphagia, and was found to have a type 3 advanced gastric cancer with bilateral multiple lung metastases. This patient was treated with low-dose 5-FU plus CDDP chemotherapy. In the first course, CDDP (6 mg/m2/day) plus 5-FU (300 mg/m2/day) were infused for 5 successive days a week, but a tumor response was not achieved. Therefore, in the second course, CDDP (6 mg/m2/day) plus 5-FU (600 mg/m2/day) were infused every other day (3 days a week). In response to the treatment, both the gastric tumor and the lung metastases almost completely disappeared (reduction rate 95%), and PR was achieved. The CEA level markedly decreased, from 260.3 to 1.4 ng/ml and the patient's symptoms disappeared. Following this treatment, low-dose CDDP plus UFT therapy was performed and the PR was maintained for 12 months. This report shows a case of advanced gastric cancer that responded to low-dose 5-FU plus CDDP.

Metastasis of hepatocellular carcinoma to spleen and small intestine.

Metastasis of cancer to the spleen or small intestine is rare. We encountered a case of hepatocellular carcinoma (HCC) with splenic and jejunal metastases. A 60-year-old man was referred to us in February 2005 with a diagnosis of splenic tumor. Since 2001, he had been treated repeatedly for HCC with liver cirrhosis due to hepatitis C virus infection; partial liver resection, transcatheter arterial chemo-embolization, and radiofrequency ablation therapy had been performed. In October 2004, he had undergone partial pulmonary resection due to metastasis of HCC to the lung. The splenic tumor, which was detected by computed tomography, seemed to be a metastasis of HCC. Splenectomy was performed for the splenic tumor, and a jejunal tumor was discovered and also resected. Both the splenic and jejunal tumors were diagnosed pathologically as metastases from the HCC. After repeated treatment for HCC, metastases can appear in various organs; thus, careful observation is necessary during follow-up.

Receptor activator of nuclear factor-kappaB ligand (RANKL) expression in hepatocellular carcinoma with bone metastasis.

BACKGROUND: Although receptor activator of nuclear factor-kappaB ligand (RANKL) seems to be involved in the development of bone metastases in several malignant tumors, its role in hepatocellular carcinoma (HCC) has not been investigated. METHODS: We retrospectively examined the immunohistochemical expression of RANKL in formalin-fixed, paraffin-embedded resected specimens obtained from 96 patients with HCC with (n = 16) and without (n = 80) bone metastases. In addition, tumor RANKL mRNA expression was evaluated by reverse transcriptase-polymerase chain reaction (RT-PCR) in five selected patients. We analyzed the relationship between RANKL expression level, bone metastasis development, and survival rate of patients with HCC after hepatic resection. RESULTS: Of the 96 patients with HCC, serum hepatitis C virus antibody was detected in 43.5% of patients and hepatitis B surface antigen in 29.5% of patients. Thirty-three patients (36.5%) also had liver cirrhosis. Immunohistochemical analysis showed that RANKL protein was present in 10 (62.5%) of 16 patients with HCC with bone metastasis compared with 21 (26.3%) of 80 patients with HCC without bone metastasis; we found that RANKL expression was statistically significantly correlated to bone metastasis development (P < .01). RANKL mRNA expression was confirmed by RT-PCR in patients positive for RANKL protein expression by immunohistochemistry. The 5-year cancer-related (P < .01) and disease-free survival (P < .01) rates after hepatic resection were statistically significantly worse in patients positive for RANKL expression compared with RANKL-negative patients. CONCLUSIONS: Some HCC cells produced the crucial bone resorption regulator RANKL. Because RANKL modulates bone turnover, its presence would have profound implications for the establishment and development of bone metastases.

Immunoactivative role of indoleamine 2,3-dioxygenase in human hepatocellular carcinoma.

BACKGROUND: Indoleamine 2,3-dioxygenase (IDO) is a tryptophan catabolic enzyme. Recent studies have focused on the immunoregulatory role of IDO in mononuclear cells. The role of IDO in hepatocellular carcinoma (HCC) cell lines and HCC patients was examined. METHODS: The expression of IDO mRNA in peripheral blood mononuclear cells (PBMC) cocultured with HCC cell lines was detected by reverse transcriptase-polymerase chain reaction (RT-PCR). The cytotoxicity of PBMC against HCC cell lines cultured with and without IDO inhibitor was examined by sodium 51chromate release assay. In the tumor portion of 21 HCC patients, the expression of mRNA of IDO, tryptophan 2,3-dioxygenase and some cytokines was detected by RT-PCR. The expression and distribution of IDO protein in HCC specimens was analyzed by immunohistochemistry. RESULTS: The IDO mRNA was strongly induced in PBMC cocultured with HepG2 and PLC/PRF/5 and faintly induced in PBMC cocultured with Hep3B and HuH7. The cytotoxicity of PBMC against HCC cell lines was directly proportional to the level of expression of IDO mRNA and reduced by IDO inhibitor. The expression of IDO mRNA in the tumor portion was detected in 12 out of 21 HCC patients. Immunohistochemistry revealed that the IDO-positive cells were identified to be tumor-infiltrating cells, not tumor cells. The IDO mRNA correlated significantly with gene expression of interferon-gamma, tumor necrosis factor-alpha and interleukin-1beta. The recurrence-free survival rate of IDO-positive HCC patients was significantly higher than that of IDO-negative HCC patients (P<0.05). CONCLUSIONS: These results suggest that IDO is a necessary enzyme for anticancer immune reactions of tumor-infiltrating cells.

Clear cell carcinoma of the pancreas: an adenocarcinoma with unusual phenotype of duct cell origin.

Although clear cell carcinoma has been found in various organs, only six cases have been reported in the pancreas. Moreover, the histogenesis of clear cell carcinoma of the pancreas remains controversial. We report a case of clear cell carcinoma of the pancreas in a 61-year-old woman, with an unusual pheno- or genotype detected by histochemical, immunohistochemical, and K- ras oncogene analyses. Histologically, the pancreatic tumor was predominantly composed of clear cell nests with scanty fibrous stroma and scattered duct-like structures. Neither clear cell nor duct-like components of the tumor showed mucin production. Immunohistochemical analysis of neoplastic cells showed a positive reaction to antibodies against cytokeratins 8 and 19, carbohydrate antigen 19-9, and alpha-1-antitrypsin, and showed no reaction to antibodies against carcinoembryonic antigen, neuroendocrine markers, trypsin, amylase, and HMB45. K- ras analysis revealed no mutation at codon 12 in either clear cell or duct-like components. The patient has had no recurrence as yet. The pancreatic carcinoma in our patient may be of duct cell origin, but the results of histochemical, immunohistochemical, and gene analyses and patient's outcome were unusual compared with those of previous cases.