Impact of preoperative percutaneous transhepatic biliary drainage on post-operative survival in patients with distal cholangiocarcinoma.

BACKGROUND: The aim of this study was to investigate the long-term impact of the type of preoperative biliary drainage used for patients undergoing pancreatoduodenectomy for distal cholangiocarcinoma (DCC). METHODS: A total of 84 patients with DCC who underwent preoperative biliary drainage between June 2000 and December 2016 were divided into groups for whom percutaneous transhepatic biliary drainage (PTBD) (n = 24) or endoscopic biliary drainage (EBD) (n = 60) was used. RESULTS: The 5-year overall survival in the PTBD group was significantly worse than that in the EBD group (16.7% versus 52.3%, P = 0.007). After propensity score matching (22 patients in each group), the 5-year overall survival in the PTBD group was still worse than that in the EBD group (13.6% versus 61.2%, P = 0.003). Multivariate analysis revealed that PTBD was independent risk factor for both poor survival (P = 0.028) and peritoneal recurrence (P = 0.018). The incidence of multiple sites at initial recurrence tended to be higher in the PTBD group than in the EBD group (P = 0.080). CONCLUSIONS: PTBD should not be performed for patients undergoing pancreatoduodenectomy for DCC, except when EBD is contraindicated, as PTBD is significantly associated with shorter survival and peritoneal recurrence.

A case of gastric heterotopic pancreatitis resected by laparoscopic surgery.

Heterotopic pancreas (HP) is a rare entity which is defined as the presence of pancreatic tissue lacking anatomical and vascular continuity with the pancreas. It is most commonly found along foregut derivatives, such as the stomach, duodenum, and jejunum. It is frequently encountered incidentally in asymptomatic patients, and symptomatic patients are rare and do not exhibit any specific symptoms. Accordingly, HP is difficult to diagnose before surgery. Here we report an unusual case of gastric heterotopic pancreatitis causing gastric outlet obstruction diagnosed preoperatively using endoscopic ultrasonography guided fine needle aspiration cytology. A 21-year-old woman was referred to our hospital because of abdominal pain, nausea, and vomiting. Gastroduodenal endoscopic examination revealed an oval-shaped submucosal tumor in the gastric body. Contrast-enhanced computed tomography (CT) revealed that the tumor had a cystic component and marked perigastric inflammation. Endoscopic ultrasonography (EUS) demonstrated a hypoechoic mass arising from the third to fourth layer of the gastric wall. Pancreatic exocrine glands were detected by EUS-guided fine needle aspiration biopsy. The lesion was diagnosed as gastric heterotopic pancreas with inflammation of the pancreatic tissue. Laparoscopic partial gastrectomy was performed, and the diagnosis was also histologically confirmed. The patient was discharged 5 days after the operation. She has remained healthy and symptom-free during 10 months of follow-up. We experienced a first case of gastric heterotopic pancreatitis which was correctly diagnosed preoperatively and resected by laparoscopic surgery. Partial resection of the heterotopic pancreatic tissue could lead to a good outcome.

Preoperative neutrophil-to-lymphocyte ratio for prognostication of patients with distal bile duct carcinomas undergoing surgery.

BACKGROUND: Surgical resection continues to be the current standard treatment for distal bile duct carcinoma (DBC), as no effective alternative treatment exists. However, even after resection, the long-term prognosis is poor. Simple biomarkers that can predict response or toxicity, and which are applicable to all community oncology settings worldwide, have not been identified. Differential white-cell counts, such as the neutrophil-to-lymphocyte ratio (NLR), as markers of inflammation, may be simple and readily available biomarkers. This study aimed to determine whether the NLR can be used as a predictor of surgical outcome in patients with DBC. MATERIALS AND METHODS: We enrolled 91 DBC patients who had undergone pancreatoduodenectomy (PD) at a single institution between April 2000 and December 2013. Blood was sampled on admission for determination of NLR. An NLR of ≥5 was selected as the cut-off value for validation. RESULTS: Seventeen patients had an NLR of ≥5 (Group 1; 18.7%), while 74 had an NLR of <5 (Group 2; 81.3%). The 1-, 3- and 5-year survival rates for Group 1 patients were 75.9, 34.5 and 34.5%, respectively, while those for Group 2 patients were 94.8, 55.2 and 46.6%, respectively (p = 0.02). There were no significant inter-group differences in clinicolaboratory background factors such as the mean operation time, bleeding volume, tumor size, CRP, neutrophil count and lactate dehydrogenase (LDH) level. On the other hand, there were significant inter-group differences for albumin level (p = 0.011), lymphocyte count (p = 0.001) and NLR (p < 0.001). Multivariate analyses were performed for factors such as gender, age, maximum tumor diameter, drainage method, operation time, bleeding volume, pathology, albumin, CRP, neutrophil count, lymphocyte count, LDH and NLR. The results revealed that NLR (odds ratio, 2.032; 95% CI, 0.999-4.134; p = 0.040) was associated with postoperative overall survival. CONCLUSIONS: An NLR of ≥5 predicts a poor outcome in patients undergoing PD for DBC. NLR is an independent indicator of overall survival for such patients.

Discrepancy of B cell frequency between periphery and spleen after rituximab treatment in ABO-incompatible liver transplantation.

ABO-incompatible living-donor liver transplantation (ABO-LDLT) is generally more difficult to perform than ABO-incompatible kidney transplantation. Despite introduction of rituximab, ABO-LDLT in non-responders is a still difficult issue. A 23-year-old woman with primary sclerosing cholangitis underwent LDLT. The recipient's blood type was 0(+) and the donor's was B(+). Rituximab was infused twice on preoperative day (POD) 14 and 7. Plasma exchange (PE) was performed on PODs 5, 3, 2, and 1. However, repeated PE failed to decrease the anti-B antibody titer. On the other hand, preoperative esophagogastroscopy revealed esophageal varices with red color sign. Therefore, simultaneous liver transplantation and Hassab operation were performed. The donor left lobe of the liver was orthotopically transplanted into the recipient following Hassab operation. Flow cytometry on the day of surgery showed that the frequencies of B cells (CD20+) and memory B cells (CD20+/CD27+) in the peripheral blood were 0.9% and 0.3%, respectively; flow cytometry of cells recovered from the spleen revealed that the frequencies of B cells and memory B cells were 2.5% and 2.4%, respectively. Acute cellular rejection occurred on POD 15, and was treated by steroid pulse therapy, leading to a decrease in the anti-B antibody titer. The liver was functioning well on POD 390 (AST 19, ALT 34). In non-responders to ABO-LDLT, anti-donor blood type antibody-producing cells remains in the spleen after the conventional preoperative regimen. Splenectomy is an option for ABO-LDLT non-responders.

Endoscopy-assisted transanal division of an apical pouch bridge after restorative proctocolectomy with a J-shaped ileal pouch.

Restorative proctocolectomy and J-shaped ileal pouch-anal anastomosis have been performed as a standard operation for ulcerative colitis. However, functional problems are sometimes troublesome in the postoperative period. The J pouch was constructed from 2 ileal limbs using the gastrointestinal anastomosis (GIA) stapler. A residual mucosal bridge remained because the stapler had a safety margin at the top of the cartridge. Apical pouch bridge is a residual septum above the ileoanal anastomosis. There are several reports of so-called apical pouch bridge syndrome due to outlet obstruction of the J-shaped ileal pouch by an apical bridge. Division of this septum can resolve the outlet obstruction. We describe a successful endoscopic procedure for division of an apical pouch bridge. An Endo-GIA stapler was introduced into the ileal pouch alongside the endoscope, and division of the apical bridge required a few firings of the Endo-GIA stapler under transanal endoscopic guidance. The symptoms related to the apical pouch bridge were resolved completely without creation of an ileostomy.