An invaginated pancreaticogastrostomy following subtotal stomach-preserving pancreaticoduodenectomy: A prospective observational study.

BACKGROUND/OBJECTIVE: Postoperative pancreatic fistula (POPF) leads to life-threatening complications after pancreaticoduodenectomy (PD). Pancreaticogastrostomy (PG) often adopted as a reconstruction technique after PD to prevent POPF. Delayed gastric emptying (DGE) following PD is the most common complication that compromises the quality of life. Subtotal stomach-preserving PD (SSPPD) preserves the pooling ability of the stomach and minimize the occurrence of DGE. This study aimed to describe our PG technique following SSPPD and evaluate the perioperative outcomes. METHODS: The study included patients who underwent PG following SSPPD from August 2013 to July 2020 at our institution. An invaginated PG was performed by one-layer eight interrupted sutures with a lost stent. Patients' demographics and perioperative outcomes were documented. RESULTS: This technique was applied in 72 patients with a median age of 75 years. The median operative time was 342 min. The clinically relevant POPF, DGE and post-pancreatectomy hemorrhage was 4 (5.6%), 5 (6.9%), and 10 (13.9%), respectively. Although the drain fluid amylase concentration on postoperative day 3 was significantly higher in clinically relevant POPF (CR-POPF) positive group (median, 2006 U/L vs. 74 U/L in CR-POPF negative group, p = 0.002), none of the risk factors including disease pathology, pancreatic duct diameter, texture of pancreas and excessive blood loss were significantly associated with CR-POPF. Other morbidity ≥ Clavien-Dindo classification II occurred in 29 patients (40.3%). The 90-days operative mortality was two (2.8%). CONCLUSIONS: This novel method of one-layer invaginated PG following SSPPD is safe and dependable procedure with acceptable morbidity and mortality.

Pancreaticoduodenectomy after transcatheter aortic valve implantation in an elderly patient with severe aortic stenosis and pancreas cancer: A case report.

INTRODUCTION AND IMPORTANCE: Not only pancreatic cancer but also aortic stenosis (AS) is increasing with the aging population. There is no optimal strategy for elderly patients with both pancreatic cancer and AS. We report a case of pancreatic head cancer with severe AS undergoing pancreaticoduodenectomy (PD) after transcatheter aortic valve implantation (TAVI). CASE PRESENTATION: An 88-year-old woman was referred to our hospital because of severe AS with symptoms of heart failure. Preoperative examination revealed resectable pancreatic head cancer, so TAVI was performed before PD to reduce the perioperative risk. The patient underwent PD 34 days after TAVI, with no significant postoperative complications, and was transferred to the other hospital for rehabilitation on postoperative day 45. No recurrence was observed at more than 7 months without adjuvant therapy. CLINICAL DISCUSSION: Aortic valve replacement (AVR) is recommended before non-cardiac surgery in patients with symptomatic severe AS. Surgical aortic valve replacement (SAVR) is the standard treatment. However, owing to the highly invasive procedure and increased perioperative risk, SAVR is usually avoided in elderly patients with malignancy and severe AS. We demonstrated that TAVI followed by PD could be safely performed in high-risk elderly patients presenting with both severe AS and pancreatic head cancer. To our knowledge, this is the first case report of PD after TAVI in a patient with severe AS. CONCLUSION: We demonstrated that TAVI followed by PD could be safely performed in high-risk elderly patients presenting with severe AS and co-existing malignancy.

Impact of antithrombotic therapy on the outcomes with focus on bleeding and thromboembolic events in patients undergoing pancreticoduodenectomy.

BACKGROUND: We investigated perioperative outcomes of pancreaticoduodenectomy (PD) in patients receiving antithrombotic therapy (ATT) with a focus on the incidence of perioperative bleeding and thromboembolic complications. METHODS: A total of 77 patients who underwent PD at our institution between 2013 and 2019 were retrospectively reviewed. Clinical findings and surgical outcomes including bleeding and thromboembolic complications were compared in patients with or without ATT. Interruption of ATT and perioperative heparin bridging were based on our hospital protocol. RESULTS: Among ATT (30) and non-ATT (47) groups, ATT group had a significantly higher age and history of cardiocerebrovascular diseases. No significant difference was observed in intraoperative and post-pancreatectomy haemorrhage (PPH) between the groups. ATT group was associated with a significantly higher rate of post-operative complications, Clavien-Dindo classification ≥II and thromboembolic events. Operative mortality in ATT and non-ATT groups was 2 (6.7%) and 1 (2.1%), respectively. There was no significant association between ATT and excessive intraoperative blood loss (≥1000 mL), PPH (≥grade B) and thromboembolic complications (Clavien-Dindo classification ≥II). CONCLUSION: In patients with ATT, PD is a feasible procedure with no major impact on intraoperative bleeding or PPH.

Interleukin 8 in human hepatocellular carcinoma correlates with cancer cell invasion of vessels but not with tumor angiogenesis.

BACKGROUND: Angiogenic factor seems necessary for the development of hepatocellular carcinoma (HCC), which is a hypervascular malignancy. This study examined the expression of interleukin (IL)-8, a potent angiogenic factor, in HCC samples. METHODS: We measured IL-8 expression by using reverse transcriptase-polymerase chain reaction in clinical HCC tissues from 45 patients who underwent surgical resection. We then assessed correlations between IL-8 expression and microvessel growth or clinicopathologic factors. We also elucidated the in vitro effect of IL-8 on HepG2 development by using fluorometric assays of proliferation, chemotaxis, and invasion. RESULTS: The expression of IL-8 did not significantly correlate with the microvessel count in HCC tissues, but the incidence of microscopic vessel invasion was significantly higher in IL-8-positive than in IL-8-negative tissues. Thus, more IL-8 was expressed in HCCs at pathologic stage III/IV than in those at stage I/II. Assays in vitro showed that IL-8 stimulates HepG2 chemotactic and invasive activities rather than cell proliferation. CONCLUSIONS: The expression of IL-8 in human HCC has more relevance to metastatic potential, such as vessel invasion, than to angiogenesis or cell proliferation.

A potential role of hyperbaric oxygen exposure through intestinal nuclear factor-kappaB.

OBJECTIVE: Recent studies have demonstrated the therapeutic effectiveness and pharmacologic mechanisms of hyperbaric oxygen therapy (HBOT) in the treatment of a systemic shock state. To elucidate the in vivo role of HBOT during sepsis, we evaluated the effects of HBOT on intestinal mucosal injury and bacterial translocation after lipopolysaccharide challenge. DESIGN: Experimental study. SETTING: First Department of Surgery and Division of Emergency Care, Kagoshima University School of Medicine, Kagoshima, Japan. SUBJECTS: : Male rats were treated with lipopolysaccharide by an intraperitoneal route or with lipopolysaccharide and HBOT. INTERVENTIONS: The survival rate, small intestinal tissue damage, and bacterial translocation in the HBOT-treated group were compared with those in the untreated group. Moreover, plasma tumor necrosis factor-alpha and nitrite/nitrate concentrations, inducible nitric oxide synthase and myeloperoxidase activities, and nuclear factor-kappaB in ileal mucosa were investigated. HBOT was initiated 3 hrs after lipopolysaccharide challenge and administered as 100% oxygen, at 2.53 x 10 kPa (2.5 atm absolute), for 60 mins. MEASUREMENTS AND MAIN RESULTS: When a sublethal dose of lipopolysaccharide (24 mg/kg) was given, the survival rate was much better in the HBOT-treated group (75%) than in the untreated group (33%). HBOT given 3 hrs after lipopolysaccharide injection (10 mg/kg) also lessened the histologic tissue damage of the terminal ileum and the incidence and magnitude of bacterial translocation to mesenteric lymph nodes at 24 hrs after the lipopolysaccharide injection. Moreover, HBOT was able to reduce mucosal inducible nitric oxide synthase and myeloperoxidase activities and plasma nitrite/nitrate concentrations but not serum tumor necrosis factor-alpha concentrations. Immunohistochemical examination revealed that HBOT specifically modified the mucosal nuclear factor-kappaB activation within 4-6 hrs after the injection. CONCLUSIONS: HBOT performed 3 hrs after lipopolysaccharide challenge alleviates intestinal barrier dysfunction and improves survival rates. Herein, we propose one possible mechanism for these beneficial effects: HBOT can modify the nuclear factor-kappaB activation in the intestinal mucosa and attenuate the sequential nitric oxide overproduction and myeloperoxidase activation. Consequently, bacterial translocation could be potentially decreased. We believe that the present study should lead to an improved understanding of HBOT's potential role in sepsis.

Prognostic performance of the new classification of primary liver cancer of Japan (4th edition) for patients with hepatocellular carcinoma: a validation analysis.

The Japanese staging system that is generally used for hepatocellular carcinoma (HCC) (3rd edition) was considerably revised recently, especially T category. No study, however, has revealed how well the new classification (4th edition) works to stratify HCC patients at a pre-intervention stage. The purpose of this study is to assess the discriminatory value and predictive power of the 4th edition, and to compare its utility with the clinical utilities of the 3rd edition and the cancer of the liver Italian program (CLIP) score, as determined from 662 Japanese patients. We performed a retrospective analysis of the HCC diagnoses at four Japanese institutions from 1990 and 1998. Overall survival was the only end-point used in the analysis. The discriminatory ability and homogeneity of the 4th edition were compared to those of the 3rd edition and the CLIP score. As of January 1999, 440 patients (66.4%) had died. The overall median survival was 37.7 months. Liver function and tumor variables, which are already accounted for by the different scoring systems, were significantly associated with survival. Compared with the 3rd edition, the 4th editions' discriminatory ability (tested by the linear trend test) and homogeneity of survival within each category (tested by the likelihood ratio test) were enhanced in both the overall group of patients and the subgroups of patients receiving transcatheter arterial chemoembolizations and percutaneous ethanol injections. In patients receiving surgery, however, the 4th edition's abilities were the lowest among the indices. Multivariate analysis revealed that the CLIP score that includes liver function had additional explanatory power above that of the 4th edition. These findings indicate that the 4th edition has a higher stratification value than the 3rd edition. However, this benefit is due to the non-surgical patients, rather than to the surgical patients. If the 4th edition had an additional scoring system based on its original tumor staging and liver damage, it might be highly beneficial, although relative risk ratios of those should be analyzed.

Quality of life after hepatectomy in patients with hepatocellular carcinoma: implication of change in hepatic protein synthesis.

BACKGROUND/AIMS: Surgical removal has been accepted as a therapeutic option for hepatocellular carcinoma. However, little is known about the quality of life after hepatectomy for hepatocellular carcinoma. In this report, we describe the risk factors most affecting impaired quality of life after partial hepatectomy in patients with hepatocellular carcinoma. METHODOLOGY: Ninety-six patients who received curative resections 12-60 months previously, answered our original questionnaire, mailed to them. The questions consisted of 14 items concerning physical function, social function, psychological function, physical sensation, and recognition of the disease, with a scoring system of 1, 2, and 3. Based on the pre- and postoperative serum alanine aminotransferase or cholinesterase levels at 3-month intervals during the follow-up period, the changes were classified into three types: those staying in the favorable or unfavorable range at one year (no change, Type 1 or Type 3), and those entering the unfavorable range postoperatively (Type 2). RESULTS: Total quality of life score: the sum of scores to questions 1-12, displayed two peaks of normal distribution. Based on a point of intersection of the two curves: i.e., score of 22, the patients were classified into 2 groups: those with preserved quality of life (n = 75) i.e., total quality of life scores of 12-21, and impaired quality of life, scores of 22 or more (n = 21). Older age (> or = 65 y) at hepatectomy, in the course of treatment for recurrence, and Type 2 change of serum cholinesterase level were associated with the impaired quality of life. Multivariate analysis revealed that Type 2 change of serum cholinesterase levels was an independent risk factor for an impaired quality of life. Furthermore, the patients exhibiting Type 2 change of serum cholinesterase levels were clearly impaired in their physical and social functions compared to the other patients. Hepatitis-related or cancer-related factors showed no correlation with the deterioration of the quality of life. CONCLUSIONS: The quality of life after hepatectomy in patients with hepatocellular carcinoma was impaired in cases of aged patients, treatment for recurrence, and Type 2 change of the serum cholinesterase level. Postoperative maintenance of protein synthesis including cholinesterase is one measure to preserve a satisfactory quality of life after hepatectomy.