Gastric intramural metastasis caused by needle tract seeding after preoperative fine needle aspiration for pancreatic body cancer subsequently resected by total pancreatectomy: a case report and literature review.

BACKGROUND: Recently, there has been an increase in the number of reports of needle tract seeding (NTS) of tumor cells after a biopsy as one of the adverse events related to endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA). In most of the previously reported cases of NTS in pancreatic cancer, distal pancreatectomy was performed as the initial surgery, following which metachronous metastasis was discovered in the gastric wall, whose localization matched the puncture route of the EUS-FNA. We report a case of early metastasis from pancreatic cancer in the gastric wall, which was postulated to be caused by NTS. Our patient underwent a total pancreatectomy (TP), and the NTS was resected synchronously. CASE PRESENTATION: A 70-year-old woman with a diagnosis of pancreatic head-body-tail cancer presented to our department for surgery. Transgastric EUS-FNA and biopsy established the histological diagnosis in her case. We administered neoadjuvant chemotherapy (NAC) to the patient and performed a TP. Histopathological and immunohistochemical examination subsequently confirmed the diagnosis of pT3N1aM1 pancreatic adenocarcinoma and its gastric metastasis, which was caused by NTS. It is postulated that the tumor cells of NTS had progressed to develop the metastatic lesion in the gastric wall during the NAC period. This was also resected during the initial surgery. The patient developed an early postoperative recurrence in the peritoneum 8 months after the surgery. CONCLUSION: In pancreatic head cancer cases, the puncture route is often included in the resection area of radical surgery, and NTS is seldom considered as a potential clinical problem. However, NTS can progress rapidly and may be associated with early recurrence of malignancy. Therefore, when transgastrointestinal puncture is performed for the diagnosis of pancreatic cancer, the treatment strategy should be established considering the potential development of NTS.

Treatment strategy for pancreatic head cancer with celiac axis stenosis in pancreaticoduodenectomy: A case report and review of literature.

BACKGROUND: During pancreaticoduodenectomy in patients with celiac axis (CA) stenosis due to compression by the median arcuate ligament (MAL), the MAL has to be divided to maintain hepatic blood flow in many cases. However, MAL division often fails, and success can only be determined intraoperatively. To overcome this problem, we performed endovascular CA stenting preoperatively, and thereafter safely performed pancreaticoduodenectomy. We present this case as a new preoperative treatment strategy that was successful. CASE SUMMARY: A 77-year-old man with a diagnosis of pancreatic head cancer presented to our department for surgery. Preoperative assessment revealed CA stenosis caused by MAL. We performed endovascular stenting in the CA preoperatively because we knew that going into the operation without a strategy could lead to ischemic complications. Double-antiplatelet therapy (DAPT) - which is needed when a stent is inserted - was then administered in parallel with neoadjuvant chemotherapy (NAC). This allowed us to administer DAPT for a sufficient period before the main pancreaticoduodenectomy procedure while obtaining therapeutic effects from NAC. Subtotal stomach-preserving pancreaticoduodenectomy was then performed. The operation did not require any unusual techniques and was performed safely. Postoperatively, the patient progressed well, without any ischemic complications. Histopathologically, curative resection was confirmed, and the patient had no recurrence or complications due to ischemia up to six months postoperatively. CONCLUSION: Preoperative endovascular stenting, with NAC and DAPT, is effective and safe prior to pancreaticoduodenectomy in potentially resectable pancreatic cancer.

Time limit to rescue intestine with viability at risk caused by blood flow disruption in patients presenting with acute abdomen.

PURPOSE: Early management is crucial for acute intestinal blood flow disorders; however, no published study has identified criteria for the time limit for blood flow resumption. This study specifically examines the time factors for avoiding intestinal resection. METHODS: The subjects of this retrospective cohort study were 125 consecutive patients who underwent emergency surgery for a confirmed diagnosis of intestinal strangulation (n = 86), incarceration (n = 27), or volvulus (n = 12), between January 2015 and March 2021. Intestinal resection was performed when intestinal irreversible changes had occurred even after ischemia was relieved surgically. We analyzed the relationship between the time from computed tomography (CT) imaging to the start of surgery (C-S time) and intestinal resection using the Kaplan-Meier method and calculated the estimated intestinal rescue rate. Patient background factors affecting intestinal resection were also examined. RESULTS: The time limit for achieving 80% intestinal rescue rate was 200 min in C-S time, and when this exceeded 300 min, the intestinal rescue rate dropped to less than 50%. Multivariate analysis identified the APACHE II score as a significant influencing factor. CONCLUSION: A rapid transition from early diagnosis to early surgery is critical for patients with acute abdomen originating from intestinal blood flow disorders. The times from presentation at the hospital to surgery should be reduced further, especially for severe cases.

Single-incision laparoscopic excision of symptomatic accessory spleen in the pelvis: An initial report.

An accessory spleen (AS) is commonly located near the spleen's hilum and/or in the pancreas tail. However, a symptomatic AS is rarely found in the pelvis. We present a resected case with lower abdominal pain whose final diagnosis was symptomatic AS caused by torsion in the pelvis. An 18-year-old man was presented to our hospital with lower abdominal pain. Enhanced abdominal computed tomography showed an inflammatory mass with a cord-like band in the pelvic space. We finally diagnosed pelvic neoplasm and performed single-incision laparoscopic surgery (SILS) using an access platform. SILS of these tumours located on a pelvic lesion has never been reported; this is the first report of torsion of a pelvic AS. SILS for AS is a safe, feasible procedure, even when the AS lays in the pelvic space.

Significance of ductal margin status in patients undergoing surgical resection for extrahepatic cholangiocarcinoma.

OBJECTIVES: The objective of this study was to determine whether carcinoma in situ at the bile duct margin is prognostically different from residual invasive carcinoma in patients with extrahepatic cholangiocarcinoma. Although there are many reports that the ductal margin status at bile duct resection stumps is a prognostic indicator in patients with extrahepatic cholangiocarcinoma, some patients who undergo resection with microscopic tumor involvement of the bile duct margin survive longer than expected. METHODS: A retrospective clinicopathological analysis of 128 patients who had undergone surgical resection for extrahepatic cholangiocarcinoma was conducted. The status of the bile duct resection margin was classified as negative in 105 patients (82.0%), positive for carcinoma in situ in 12 patients (9.4%), and positive for invasive carcinoma in 11 patients (8.6%). RESULTS: Ductal margin status was an independent prognostic indicator by both univariate (p = 0.0022) and multivariate (p = 0.0105) analyses, along with lymph node metastasis. There was no significant difference between patients with a negative ductal margin and those with a positive ductal margin with carcinoma in situ (p = 0.5247). The 5-year survival rate of patients with a positive ductal margin with carcinoma in situ (22.2%) was significantly better (p = 0.0241) than with invasive carcinoma (0%). There was a significant relationship between local recurrence and ductal margin status (p = 0.0401). CONCLUSIONS: Among patients undergoing surgical resection for extrahepatic cholangiocarcinoma, invasive carcinoma at the ductal resection margins appears to have a significant relation to local recurrence and also a significant negative impact on survival, whereas residual carcinoma in situ does not. Discrimination whether carcinoma in situ or invasive carcinoma is present is important in clinical setting in which the resection margin at the ductal stump is positive.

Portal vein reconstruction using a left renal vein graft for a patient with hilar cholangiocarcinoma.

We report a patient with hilar cholangiocarcinoma who underwent combined portal vein reconstruction using a left renal vein graft. A 68-year-old man was referred to the hospital with a one-week history of dark urine and jaundice. Cholangiography through the percutaneous transhepatic biliary drainage catheter and magnetic resonance cholangiopancreatography demonstrated complete obstruction of the hepatic primary confluence extended to the left secondary confluence. The patient underwent left hepatic lobectomy combined with total caudate lobectomy and extrahepatic bile duct resection. At operation, carcinoma invasion was observed from the portal trunk to the right portal branch. So, combined portal vein resection and graft interpose using left renal vein was performed. The caliber of left renal vein was wider than the right portal branch. No remarkable renal and hepatic dysfunction occurred postoperatively. In conclusion, left renal vein seems appropriate as an autograft when reconstructing the portal vein, especially main portal trunk, in patients with advanced hepatobiliary malignancies. It may be necessary to adjust the caliber when anastomosing the left renal vein to the right or left portal branch because the diameter of the left renal vein is usually wide.

Significance of extensive surgery including resection of the pancreas head for the treatment of gallbladder cancer--from the perspective of mode of lymph node involvement and surgical outcome.

The present study aimed to clarify the efficacy of extensive surgery, including pancreas head resection, for more complete lymphadenectomy in the treatment of gallbladder carcinoma. The study involved retrospective analyses of 65 consecutive patients with gallbladder carcinoma who underwent surgical resection between 1982 and 2003. Of these 65 patients, 41.5% displayed node-positive disease and among them 23.1% had positive para-aortic nodes. Of six node-positive 5-year survivors, five underwent pancreatoduodenectomy combined with S4aS5 hepatic subsegmentectomy. The 5-year survival rates were 76.2% for pN0, 30.0% for pN1, 45.8% for pN2, and 0% for pM1[lymph], respectively. Significant differences existed in survival rates. Postoperative recurrence was observed in 24.1% (13/54) of patients who underwent R0 resection. Of the four patients who displayed lymph node recurrence, two had pericholedocal and/or posterior pancreatoduodenal lymph node metastasis at the time of surgery and underwent pancreas-preserving regional lymphadenectomy. These results suggest that extensive resection, including resection of the pancreatic head, is effective in selected patients with up to pN2 lymph node metastasis, as long as complete removal of the cancer can be achieved. Pancreatoduodenectomy combined with S4aS5 hepatic subsegmentectomy should be considered when lymph node metastasis is obvious and the patient is in good condition.

Clinicopathological study of depth of subserosal invasion in patients with pT2 gallbladder carcinoma.

BACKGROUND: We examined whether depth of subserosal cancer invasion predicts lymph node involvement and survival in gallbladder carcinoma (GBC) patients with pathologicial subserosal invasion (pT2), to explore which patients benefit from radical second resection among patients with inapparent pT2 tumor. METHODS: Subjects comprised 31 patients with pT2 GBC. Thickness of the subserosal layer and vertical length of carcinoma invasion into the subserosa were measured under microscopy. Depth of subserosal invasion was divided subjectively into three categories: ss1, ss2, and ss3 (invasion of upper, middle, and lower thirds of the subserosal layer, respectively). Relationships between subserosal subclassification, histopathological factors, and prognosis were examined. RESULTS: Subserosal layers were significantly thicker (P < 0.001) in portions with cancer invasion (5.46 +/- 0.68 mm; range 1.0 approximately 13.75 mm) than those without cancer invasion (1.89 +/- 0.16 mm, range, 0.88 approximately 4.50 mm). Depth of carcinoma invasion into subserosa was 4.20 +/- 0.65 mm (range, 0.25 approximately 12.5 mm). Rate of lymphatic permeation, venous permeation, and lymph node involvement significantly increased with deeper subserosal invasion (P = 0.014, P = 0.027, P = 0.018, respectively). Among histopathological factors examined, only subserosal subclassification had a significant correlation with presence or absence of lymph node metastasis. Further, there was a significant correlation (P = 0.043) between the degree of subserosal invasion (ss1, ss2, and ss3) and involved nodal disease (pN0, pN1, and pM1 [lymph]). Although 5-year survival rates, according to the degree of subserosal invasion, tended to decrease with deeper invasion into the subserosal layer (ss1, 83.3%; ss2, 62.5%; ss3, 50.0%), no significant differences were noted. CONCLUSIONS: Pathological characteristics tend to become more aggressive with increasing depth of subserous carcinoma invasion in pT2 GBC. Depth of subserosal invasion is a predictor of presence and degree of lymph node metastasis in pT2 GBC. A sampling biopsy of the para-aortic nodes is recommended for inapparent pT2 GBC patients with subserosal invasion beyond one-thirds of the subserosal layer when they undergo radical second resection.

[Oncologic emergencies associated with pancreatobiliary cancer].

Clinically common oncologic emergencies associated with pancreatobiliary cancer are gastrointestinal bleeding caused by duodenal invasion of pancreatic carcinoma, severe duodenal obstruction due to pancreatic carcinoma, and acute cholangitis accompanied by obstructive jaundice in patients with biliary tract carcinoma. When a patient with gallbladder cancer presents with acute cholecysitis, emergency surgery is sometimes performed on the basis of the latter diagnosis. Emergency procedures can also be required in the perioperative management of pancreatobiliary cancer, for example, in biliary peritonitis caused by detachment of a percutaneous transhepatic biliary drainage (PTBD) tube and in ruptured pseudoaneurysm due to postoperative pancreatic or biliary leakage. Nonsurgical procedures are usually initially selected for oncologic emergencies associated with pancreatobiliary cancer, because patients are likely to develop severe organ dysfunction and it is difficult to access directly and remove the pancreas or biliary tract during emergency surgery. When systemic conditions improve, it is necessary to evaluate the degree of disease progression and systemic conditions, and if feasible, the primary lesion should be surgically resected. When performing emergency cholecystectomy in patients with acute cholecystitis, thorough intraoperative investigation of resected specimens is important, considering the possibility of concomitant gallbladder carcinoma, since thorough examination cannot be performed in such emergency settings. Furthermore, when cholangitis accompanies pancreatobiliary cancer, emergency drainage should be considered as sepsis can develop rapidly.

Long-term results of central inferior (S4a+S5) hepatic subsegmentectomy and pancreatoduodenectomy combined with extended lymphadenectomy for gallbladder carcinoma with subserous or mild liver invasion (pT2-3) and nodal involvement: a preliminary report.

BACKGROUND/AIMS: Gallbladder carcinoma, especially advanced cancer that has invaded the subserosal or deeper layers, has a poor prognosis. Recently, radical operations combining resection of the liver and pancreas with extended lymph node dissection have been introduced to improve the prognosis of advanced gallbladder carcinoma. We have introduced central inferior (Couinaud's subsegments 4a and 5; S4a+S5) hepatic subsegmentectomy and pancreatoduodenectomy combined with extended lymphadenectomy for gallbladder carcinoma demonstrating subserous or mild liver invasion (pathological tumor stage pT2-3) and nodal involvement. METHODOLOGY: Morbidity, mortality, clinicopathological features, and long-term outcome were analyzed retrospectively for seven consecutive patients who underwent this radical operation. RESULTS: The postoperative morbidity rate was 57.1% and there was no surgical mortality. All patients had lymph node involvement: two had pN1 disease and five had pN2 disease. All patients underwent curative resection. Only one patient developed gallbladder carcinoma recurrence after resection and it involved the paraaortic lymph nodes. Five patients, three of whom displayed pN2 disease, survived longer than 5 years postoperatively with no evidence of disease. CONCLUSIONS: S4a+S5 hepatic subsegmentectomy and pancreatoduodenectomy combined with extended lymphadenectomy improve the long-term survival of gallbladder carcinoma with pT2-3 and nodal involvement. The presence of pN2 disease is not a contraindication for surgery. Further study is necessary to evaluate the usefulness of this radical procedure, especially as a standard operation.

Resection of liver metastasis from extrahepatic bile duct carcinoma previously treated by pancreatoduodenectomy.

No English report of a 5-year survivor with liver metastasis from periampullary carcinoma has been published to date. Here, we report a 52-year-old woman with liver metastasis previously treated with pylorus-preserving pancreatoduodenectomy for extrahepatic bile duct carcinoma, who underwent hepatectomy and has survived for more than 5 years without recurrence after the procedure. This outcome suggests that hepatic resection is effective for selected patients with liver metastasis from extrahepatic bile duct carcinoma previously treated by pancreatoduodenectomy. When a patient has a solitary metastasis of the liver with no other evidence of recurrence, surgical resection of the liver metastasis should be considered a valid option.

Hepatopancreatoduodenectomy with wide lymph node dissection for locally advanced carcinoma of the gallbladder--long-term results.

BACKGROUND/AIMS: Although hepatopancreatoduodenectomy with wide lymph node dissection has been conducted for patients with locally advanced gallbladder carcinoma, the clinical usefulness of this radical procedure has not yet been estimated. METHODOLOGY: Morbidity, mortality, and outcome were analyzed retrospectively for 16 consecutive patients undergoing hepatopancreatoduodenectomy. RESULTS: One in-hospital fatality (6.3%) and 11 postoperative complications occurred (69%). Overall 5-year survival in this procedure was 42.9%. The 5-year survival of patients undergoing potentially curative resection (52.7%) was significantly better (P = 0.016) than those with residual tumor (0%). There was no significant correlation in 5-year survival between patients with and without lymph node metastasis. Five patients (31%) survived 5 years. Of these, 4 had Stage IVB disease, and 2 had pN2 disease. Two patients with pM1 (lymph) disease died of the disease 6 months and the other 7 months after surgery, respectively. CONCLUSIONS: Hepatopancreatoduodenectomy with wide lymph node dissection is an effective treatment for the selected patients with locally advanced gallbladder carcinoma with until pN2 disease, if curative resection is potentially feasible. Surgery is not indicated in those with pM1 (lymph) disease.